Healthcare Provider Details

I. General information

NPI: 1629254594
Provider Name (Legal Business Name): VALSAN OOMMEN RPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 01/13/2021
Certification Date: 01/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

26 JORDAN DR
MEDFORD NY
11763-2051
US

V. Phone/Fax

Practice location:
  • Phone: 631-601-4387
  • Fax:
Mailing address:
  • Phone: 917-609-8200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number012214
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: