1801827563 NPI number — DAWN MARIE D'AVERSA MS, PT

Table of content: DAWN MARIE D'AVERSA MS, PT (NPI 1801827563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801827563 NPI number — DAWN MARIE D'AVERSA MS, PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
D'AVERSA
Provider First Name:
DAWN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAYEU
Provider Other First Name:
DAWN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801827563
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3399 WINTON RD S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14623-3057
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-334-6000
Provider Business Mailing Address Fax Number:
585-334-2858

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3399 WINTON RD S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14623-3057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-334-6000
Provider Business Practice Location Address Fax Number:
585-334-2858
Provider Enumeration Date:
07/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  26819 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11450962 . This is a "CAQH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00355344 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".