Provider Demographics
NPI:1588724132
Name:MATTLE, MARQUE-ANN (PA)
Entity type:Individual
Prefix:
First Name:MARQUE-ANN
Middle Name:
Last Name:MATTLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 GREYLOCK RDG
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534-2334
Mailing Address - Country:US
Mailing Address - Phone:585-615-8939
Mailing Address - Fax:
Practice Address - Street 1:135 CORPORATE WOODS STE 200
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-1459
Practice Address - Country:US
Practice Address - Phone:585-784-7848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11668363AM0700X
NY011668363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY141338471OtherUNITED HEALTH CARE