Healthcare Provider Details

I. General information

NPI: 1003654674
Provider Name (Legal Business Name): ANTONIO MICHAEL ROSELLI PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 03/06/2025
Certification Date: 03/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL # 1118
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-1653
  • Fax: 212-289-6393
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032455
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: