Provider Demographics
NPI:1417059361
Name:DOHERTY, MEGHAN KATHLEEN (PA)
Entity Type:Individual
Prefix:MRS
First Name:MEGHAN
Middle Name:KATHLEEN
Last Name:DOHERTY
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 1:200 WEST RIDGE ROAD BUILDING 28
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14652-3402
Mailing Address - Country:US
Mailing Address - Phone:585-726-3970
Mailing Address - Fax:
Practice Address - Street 1:200 W RIDGE RD BLDG 28
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14615-2919
Practice Address - Country:US
Practice Address - Phone:585-726-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006920363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDOPA80401Medicare PIN
OHS91555Medicare UPIN