Provider Demographics
NPI:1003257809
Name:PETTINELLA, MACKENZIE R (PA)
Entity Type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:R
Last Name:PETTINELLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MACKENZIE
Other - Middle Name:R
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:DEPT. OF MEDICINE
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-723-7870
Practice Address - Fax:585-723-7871
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016626363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical