Healthcare Provider Details

I. General information

NPI: 1588448112
Provider Name (Legal Business Name): HANNA REBECCA ROAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 07/22/2025
Certification Date: 07/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8002 KEW GARDENS RD STE 107
KEW GARDENS NY
11415-3609
US

IV. Provider business mailing address

21340 CHIRPING SPARROW RD
DIAMOND BAR CA
91765-3701
US

V. Phone/Fax

Practice location:
  • Phone: 718-459-0900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number030456
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: