Provider Demographics
NPI:1306048285
Name:FROMM, INDIRA MICHELLE (RPA-C)
Entity type:Individual
Prefix:MS
First Name:INDIRA
Middle Name:MICHELLE
Last Name:FROMM
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:MS
Other - First Name:INDIRA
Other - Middle Name:MICHELLE
Other - Last Name:FROMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:307 BOW DR
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-1721
Mailing Address - Country:US
Mailing Address - Phone:631-979-1190
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK UNIVERSITY MEDICAL CTR
Practice Address - Street 2:HSC LEVEL 19 ROOM 060, DEPARTMENT OF SURGERY
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-0001
Practice Address - Country:US
Practice Address - Phone:631-444-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010213363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical