Provider Demographics
NPI:1164896874
Name:ROMAN, JONATHAN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:
Last Name:ROMAN
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10467 44TH AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-2597
Mailing Address - Country:US
Mailing Address - Phone:917-569-6742
Mailing Address - Fax:
Practice Address - Street 1:10467 44TH AVE APT 2
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-2597
Practice Address - Country:US
Practice Address - Phone:917-569-6742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-18
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY704778-1163W00000X
NYF404462-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse