Provider Demographics
NPI:1386448124
Name:ROMAN, GISSANIA
Entity type:Individual
Prefix:
First Name:GISSANIA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 LURTING AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-4409
Mailing Address - Country:US
Mailing Address - Phone:347-573-0546
Mailing Address - Fax:347-573-0546
Practice Address - Street 1:2510 LURTING AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-4409
Practice Address - Country:US
Practice Address - Phone:347-573-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-02
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2540053174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist