Provider Demographics
NPI:1285692087
Name:RODMAN, MARY J (PA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:J
Last Name:RODMAN
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:800 CARTER STREET
Mailing Address - Street 2:ATTN KELLY STEELE
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-339-4793
Mailing Address - Fax:585-336-4845
Practice Address - Street 1:77 SULLYS TRAIL
Practice Address - Street 2:
Practice Address - City:PITTSFORD
Practice Address - State:NY
Practice Address - Zip Code:14534
Practice Address - Country:US
Practice Address - Phone:585-248-5300
Practice Address - Fax:585-248-3427
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY0002661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00355266Medicaid
R88487Medicare UPIN
NY00355266Medicaid