Provider Demographics
NPI:1831524123
Name:MANCINI, TIA M (PA)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:M
Last Name:MANCINI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:M
Other - Last Name:HEWITT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-922-0553
Mailing Address - Fax:585-922-0496
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3001
Practice Address - Country:US
Practice Address - Phone:585-922-3963
Practice Address - Fax:585-266-5363
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016918363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical