Healthcare Provider Details

I. General information

NPI: 1699863100
Provider Name (Legal Business Name): STEPHANIE KAREN WARREN PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138-31-248 STREET APT 1
ROSEDALE NY
11422
US

IV. Provider business mailing address

138-31-248 STREET
ROSEDALE NY
11422
US

V. Phone/Fax

Practice location:
  • Phone: 917-864-6311
  • Fax:
Mailing address:
  • Phone: 917-864-6311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number011024
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: