Provider Demographics
NPI:1588373229
Name:PERICAK, MEGAN (NP)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:PERICAK
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 1:100 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:585-922-1900
Mailing Address - Fax:
Practice Address - Street 1:211 E 51ST ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-6526
Practice Address - Country:US
Practice Address - Phone:212-398-1709
Practice Address - Fax:646-203-0361
Is Sole Proprietor?:No
Enumeration Date:2022-11-22
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY351008363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program