Healthcare Provider Details

I. General information

NPI: 1558756247
Provider Name (Legal Business Name): DESIREE NICOLE MOHNEY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DESIREE NICOLE WAGNER MD

II. Dates (important events)

Enumeration Date: 03/31/2015
Last Update Date: 07/22/2023
Certification Date: 07/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 635
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-276-4113
  • Fax: 570-808-6072
Mailing address:
  • Phone: 585-276-4113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number317188
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number317188
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMD463914
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: