Provider Demographics
NPI:1104958909
Name:FROMMER, AVIVA (PA)
Entity type:Individual
Prefix:MS
First Name:AVIVA
Middle Name:
Last Name:FROMMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:AVIVA
Other - Middle Name:
Other - Last Name:ROSENBLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:31 PENNINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:NEW HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:10977-1418
Mailing Address - Country:US
Mailing Address - Phone:845-362-0527
Mailing Address - Fax:
Practice Address - Street 1:70 HATFIELD LN
Practice Address - Street 2:SUITE 204
Practice Address - City:GOSHEN
Practice Address - State:NY
Practice Address - Zip Code:10924-6734
Practice Address - Country:US
Practice Address - Phone:845-291-1260
Practice Address - Fax:845-294-2312
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011742363AM0700X
NJ029400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical