Healthcare Provider Details

I. General information

NPI: 1265292205
Provider Name (Legal Business Name): ROSA MORIAH GEREMIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 SALT SPRINGS RD DEPT OF
SYRACUSE NY
13214-1300
US

IV. Provider business mailing address

739 IRVING AVE STE 600
SYRACUSE NY
13210-1663
US

V. Phone/Fax

Practice location:
  • Phone: 315-320-3916
  • Fax:
Mailing address:
  • Phone: 315-701-2550
  • Fax: 315-701-2551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number034802
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: