Healthcare Provider Details

I. General information

NPI: 1164733200
Provider Name (Legal Business Name): STACEY MCGAHAN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 07/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 ELMWOOD AVE BOX 675
ROCHESTER NY
14642-0001
US

IV. Provider business mailing address

230 SIMPSON RD
ROCHESTER NY
14617-4648
US

V. Phone/Fax

Practice location:
  • Phone: 585-275-7296
  • Fax: 585-461-0662
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number335982
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: