Basic Information
| Provider Information | |||||||||
| NPI: | 1811166077 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAULKNER | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RPA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224020 | ||||||||
| FaxNumber: | 5859224622 | ||||||||
| Practice Location | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859224020 | ||||||||
| FaxNumber: | 5859224622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2008 | ||||||||
| LastUpdateDate: | 09/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 011320-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 0379650 | 05 | NY | MEDICAID |