=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518987221
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN MARIE POLCYN-DORGAN RPA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2006
-----------------------------------------------------
Last Update Date | 07/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 SOUTH AVE
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14620-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-341-6395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 SABLERIDGE CT
-----------------------------------------------------
City | SPENCERPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14559-2100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-352-1035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 6224
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 006224
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------