Healthcare Provider Details

I. General information

NPI: 1881652261
Provider Name (Legal Business Name): ILONA ROZENBERG PHYSICAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 01/26/2021
Certification Date: 01/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 STOCKHOLM ST C/O FACULTY PRACTIE
BROOKLYN NY
11237-4006
US

IV. Provider business mailing address

1723 E 12TH ST STE 4
BROOKLYN NY
11229-1070
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-6551
  • Fax: 718-963-6793
Mailing address:
  • Phone: 917-238-2195
  • Fax: 718-963-6793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number008221
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: