Healthcare Provider Details

I. General information

NPI: 1245482413
Provider Name (Legal Business Name): FAYROSE FOUAD ABODESHISHA RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2008
Last Update Date: 01/06/2025
Certification Date: 01/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVE
NEW YORK NY
10016-9196
US

IV. Provider business mailing address

331 NEWMAN SPRINGS ROAD BLDG. 2, SUITE 220
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 212-562-3917
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number23 012911
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: