Basic Information
| Provider Information | |||||||||
| NPI: | 1932433067 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KINGS HWY S | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146175504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859221900 | ||||||||
| FaxNumber: | 5859221002 | ||||||||
| Practice Location | |||||||||
| Address1: | 2655 RIDGEWAY AVE STE 420 | ||||||||
| Address2: | |||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5857237972 | ||||||||
| FaxNumber: | 5853683119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2009 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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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 | 363AM0700X | 020321 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.