Provider Demographics
NPI:1326721416
Name:DE LA ROSA JEREZ, ELAINE (PA)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:DE LA ROSA JEREZ
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 1:10504 SUTPHIN BLVD
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11435-5022
Mailing Address - Country:US
Mailing Address - Phone:855-681-8700
Mailing Address - Fax:
Practice Address - Street 1:10504 SUTPHIN BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-5022
Practice Address - Country:US
Practice Address - Phone:855-681-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030292207QA0505X, 363A00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant