Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207R00000X | Internist | 284532 | NY |
Y | 111NI0900X | Internist | 284532 | NY |
NPI | 1003251976 |
---|---|
Provider Name | Matthew Metcalf Brockway |
First Address | Penfield, NY 14526-1756 |
Second Address | Penfield, NY 14526-1756 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2013 |
Last Update Date | 08/08/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
04451061 | (05) | NY |