Provider Demographics
NPI:1962988592
Name:ROZEA, THOMAS RUSSELL
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:RUSSELL
Last Name:ROZEA
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 1:61 LARCH LN
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11762-3923
Mailing Address - Country:US
Mailing Address - Phone:516-305-7097
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-533-3414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant