Provider Demographics
NPI:1306544630
Name:ROSALIA, COLLEEN ANN (PA)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:ANN
Last Name:ROSALIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 HAWKS NEST RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1103
Mailing Address - Country:US
Mailing Address - Phone:631-413-5097
Mailing Address - Fax:
Practice Address - Street 1:895 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-2127
Practice Address - Country:US
Practice Address - Phone:631-230-5770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant