Basic Information
| Provider Information | |||||||||
| NPI: | 1366097693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAURO | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVENUE BOX 629 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146420001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2365 S CLINTON AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146182663 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857585700 | ||||||||
| FaxNumber: | 5857581299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2019 | ||||||||
| LastUpdateDate: | 08/07/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 023778 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Y00000X | 023778 | NY | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1366097693 | 05 | NY | MEDICAID |