Provider Demographics
NPI:1265628580
Name:ROSEN, MARY HEATHER (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:HEATHER
Last Name:ROSEN
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 1:76 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-1329
Mailing Address - Country:US
Mailing Address - Phone:585-786-3503
Mailing Address - Fax:585-786-3505
Practice Address - Street 1:76 N MAIN STREET
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NY
Practice Address - Zip Code:14569
Practice Address - Country:US
Practice Address - Phone:585-786-3503
Practice Address - Fax:585-786-3505
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY11923363A00000X
NY011923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02939646Medicaid
NY02939646Medicaid