Provider Demographics
NPI:1447452032
Name:HOLBROOK, SCOTT M (NP)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:M
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 MARROWBACK RD
Mailing Address - Street 2:
Mailing Address - City:CONESUS
Mailing Address - State:NY
Mailing Address - Zip Code:14435-9541
Mailing Address - Country:US
Mailing Address - Phone:585-750-7870
Mailing Address - Fax:
Practice Address - Street 1:300 WRIGHT AVENUE
Practice Address - Street 2:
Practice Address - City:MARCY
Practice Address - State:NY
Practice Address - Zip Code:13404
Practice Address - Country:US
Practice Address - Phone:315-736-8271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2022-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY400533363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY400533Medicaid