Provider Demographics
NPI:1578506515
Name:GOOTNICK, JON (PA)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:
Last Name:GOOTNICK
Suffix:
Gender:M
Credentials:PA
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:585-922-0527
Mailing Address - Fax:
Practice Address - Street 1:2685 E HENRIETTA RD
Practice Address - Street 2:
Practice Address - City:HENRIETTA
Practice Address - State:NY
Practice Address - Zip Code:14467-9370
Practice Address - Country:US
Practice Address - Phone:585-444-0058
Practice Address - Fax:585-444-0108
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2022-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002056363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical