Provider Demographics
NPI:1629084298
Name:REILLY, MAGGIE E (PA)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:E
Last Name:REILLY
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 1:117 LOMB MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-5608
Mailing Address - Country:US
Mailing Address - Phone:585-475-2255
Mailing Address - Fax:585-475-7788
Practice Address - Street 1:117 LOMB MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14623-5608
Practice Address - Country:US
Practice Address - Phone:585-475-2255
Practice Address - Fax:585-475-7788
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02618220Medicaid
NY02618220Medicaid
NYQ63917Medicare UPIN