=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598731135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY J BRANCHE PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2006
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1815 CLINTON AVE S STE 530
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-5721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-442-4310
-----------------------------------------------------
Fax | 585-442-6750
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1815 CLINTON AVE S STE 530
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14618-5721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-442-4310
-----------------------------------------------------
Fax | 585-442-6750
-----------------------------------------------------
=====================================================
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 | 006425-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MB0511217
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------