Basic Information
| Provider Information | |||||||||
| NPI: | 1932422920 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DOUGHERTY | ||||||||
| FirstName: | JAMIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2619 CULVER RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146091738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853422410 | ||||||||
| FaxNumber: | 5853429141 | ||||||||
| Practice Location | |||||||||
| Address1: | 2619 CULVER RD | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146091738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853422410 | ||||||||
| FaxNumber: | 5853429141 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2010 | ||||||||
| LastUpdateDate: | 07/02/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 013831-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.