Basic Information
| Provider Information | |||||||||
| NPI: | 1790009587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMES ROSENFELD | ||||||||
| FirstName: | RAQUEL | ||||||||
| MiddleName: | AIRES | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | GOMES | ||||||||
| OtherFirstName: | RAQUEL | ||||||||
| OtherMiddleName: | AIRES | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Practice Location | |||||||||
| Address1: | 745 STATE ROUTE 17M | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109502660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2010 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0138821 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.