Basic Information
| Provider Information | |||||||||
| NPI: | 1477883635 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RIESENBERGER | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852759555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 601 ELMWOOD AVE | ||||||||
| Address2: | BOX 655 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146428655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5852759555 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2010 | ||||||||
| LastUpdateDate: | 03/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 013768 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03574783 | 05 | NY | MEDICAID |