Provider Demographics
NPI:1366097693
Name:MAURO, MATTHEW JAMES (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:MAURO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVENUE BOX 629
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2365 S CLINTON AVE STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2663
Practice Address - Country:US
Practice Address - Phone:585-758-5700
Practice Address - Fax:585-758-1299
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY23778207Y00000X
NY023778363A00000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1366097693Medicaid