Provider Demographics
NPI:1811663875
Name:HODERLEIN, MATTHEW (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:HODERLEIN
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 1:481 PENBROOKE DR STE 6
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-2044
Mailing Address - Country:US
Mailing Address - Phone:585-338-6000
Mailing Address - Fax:
Practice Address - Street 1:481 PENBROOKE DR STE 6
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-2044
Practice Address - Country:US
Practice Address - Phone:585-388-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-19
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant