Provider Demographics
NPI:1174825657
Name:MAXWELL, PETER G (PA-C)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 HARWOOD LN
Mailing Address - Street 2:
Mailing Address - City:EAST ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14445-1914
Mailing Address - Country:US
Mailing Address - Phone:585-507-3987
Mailing Address - Fax:
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-8655
Practice Address - Country:US
Practice Address - Phone:585-275-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014448363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY014448OtherLICENSE NUMBER