Healthcare Provider Details

I. General information

NPI: 1861811986
Provider Name (Legal Business Name): RADHA GOSALIA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 VICTORY BLVD
STATEN ISLAND NY
10314-3548
US

IV. Provider business mailing address

1534 VICTORY BLVD
STATEN ISLAND NY
10314-3548
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-3577
  • Fax:
Mailing address:
  • Phone: 718-667-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number017510-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: