MEDICARE: JAMIE DOUGHERTY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	013831-1	NY

General Provider Information

NPI Number	:	1932422920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE DOUGHERTY

Provider Business Mailing Address
First Line	:	2619 CULVER RD
Second Line	:	SUITE 2A
City	:	ROCHESTER
State	:	NY
Zip	:	14609-1738
Country	:	US
Telephone Number	:	585-342-2410
Fax Number	:	585-342-9141

Provider Business Practice Location Address
First Line	:	2619 CULVER RD
Second Line	:	SUITE 2A
City	:	ROCHESTER
State	:	NY
Zip	:	14609-1738
Country	:	US
Telephone Number	:	585-342-2410
Fax Number	:	585-342-9141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2010
Last Update Date	:	07/02/2012

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