Healthcare Provider Details

I. General information

NPI: 1467221358
Provider Name (Legal Business Name): ROSHELL TVERSKAYA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2023
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 STREET RD STE 204
SOUTHAMPTON PA
18966-4218
US

IV. Provider business mailing address

1122 STREET RD STE 204
SOUTHAMPTON PA
18966-4218
US

V. Phone/Fax

Practice location:
  • Phone: 215-999-7546
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA065024
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: