Provider Demographics
NPI:1194910737
Name:FELTON, ROSCOE
Entity type:Individual
Prefix:MR
First Name:ROSCOE
Middle Name:
Last Name:FELTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:WYANDANCH
Mailing Address - State:NY
Mailing Address - Zip Code:11798-4021
Mailing Address - Country:US
Mailing Address - Phone:516-818-3135
Mailing Address - Fax:
Practice Address - Street 1:59 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:WYANDANCH
Practice Address - State:NY
Practice Address - Zip Code:11798-4021
Practice Address - Country:US
Practice Address - Phone:516-818-3135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY091409164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02339320Medicaid