Basic Information
| Provider Information | |||||||||
| NPI: | 1184109084 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PODKULSKI | ||||||||
| FirstName: | MELISSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9 OLD PLANK RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | CLIFTON PARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 120653107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5183710777 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1415 PORTLAND AVE | ||||||||
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| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224518 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2018 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 022673 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.