Provider Demographics
NPI:1154709624
Name:ROSENBLUM, ISAAC RAOUL (PA)
Entity type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:RAOUL
Last Name:ROSENBLUM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:MR
Other - First Name:ISAAC
Other - Middle Name:RAOUL
Other - Last Name:ROSENBLUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:969 MAIN ST STE D
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1791
Mailing Address - Country:US
Mailing Address - Phone:845-896-7730
Mailing Address - Fax:845-896-7758
Practice Address - Street 1:969 MAIN ST STE D
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524
Practice Address - Country:US
Practice Address - Phone:845-896-7730
Practice Address - Fax:845-896-7758
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-15
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04202728Medicaid