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General NPI Number Information
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NPI Number | 1962996520
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Entity Type | Individual
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Provider Name | MATTHEW VANDEMORTEL PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/18/2018
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Last Update Date | 09/05/2020
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Provider Practice Location Address
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Address Line | 601 ELMWOOD AVE FL 416
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City | ROCHESTER
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State | NY
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Zip | 14642-5988
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Country | US
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Telephone | 585-275-5276
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Fax |
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Provider Business Mailing Address
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Address Line | 3098 JOHNSON RD
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City | GENEVA
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State | NY
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Zip | 14456-9522
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Country | US
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Telephone | 315-237-7211
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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