Provider Demographics
NPI:1043243066
Name:ROSKO, THERESA (RPA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:ROSKO
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:
Other - Last Name:DALMASSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:148 BIG FRESH POND RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:NY
Mailing Address - Zip Code:11968-2213
Mailing Address - Country:US
Mailing Address - Phone:631-283-4451
Mailing Address - Fax:
Practice Address - Street 1:101 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-4870
Practice Address - Country:US
Practice Address - Phone:631-654-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003515363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYZ88391Medicare ID - Type Unspecified
S54418Medicare UPIN