Provider Demographics
NPI:1811627011
Name:VASSILAROS, MARY C (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:VASSILAROS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 648
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-8648
Mailing Address - Country:US
Mailing Address - Phone:585-275-2734
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:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-784-2985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310562363A00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant