Basic Information
| Provider Information | |||||||||
| NPI: | 1013971985 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEROSA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6260 82ND ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLE VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113791427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126867500 | ||||||||
| FaxNumber: | 2129515444 | ||||||||
| Practice Location | |||||||||
| Address1: | 423 E 23RD ST | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100105011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2126867500 | ||||||||
| FaxNumber: | 2129515444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 30 303835 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.