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General NPI Number Information
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NPI Number | 1598067217
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Entity Type | Individual
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Provider Name | REGINALD DEROSENA PA
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Gender | Male
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Dates
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Enumeration Date | 12/01/2010
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Last Update Date | 01/24/2022
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Provider Practice Location Address
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Address Line | 825 BROADWAY
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City | BROOKLYN
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State | NY
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Zip | 11206-7306
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Country | US
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Telephone | 718-302-9494
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Fax |
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Provider Business Mailing Address
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Address Line | 2845 ARTHUR LN
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City | WANTAGH
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State | NY
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Zip | 11793-2331
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Country | US
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Telephone | 516-410-3164
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 006005
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License Number State | NY
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