Provider Demographics
NPI:1588913594
Name:ROSA, MICHELLE T (PA)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:T
Last Name:ROSA
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 1:18 DALE LN
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-4330
Mailing Address - Country:US
Mailing Address - Phone:631-487-7084
Mailing Address - Fax:
Practice Address - Street 1:NEW YORK SPINE AND BRAIN SURGERY
Practice Address - Street 2:HSC T12 RM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8122
Practice Address - Country:US
Practice Address - Phone:631-444-1116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-05
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015933-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant