Provider Demographics
NPI:1376762062
Name:PETERSON ROBERSON, SUSAN (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:PETERSON ROBERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:410 LAKEVILLE RD
Mailing Address - Street 2:ADOLESCENT MEDICINE SUITE 109
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1101
Mailing Address - Country:US
Mailing Address - Phone:718-235-1087
Mailing Address - Fax:718-235-1291
Practice Address - Street 1:999 JAMAICA AVE
Practice Address - Street 2:ROOM 167 SBHC
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11208
Practice Address - Country:US
Practice Address - Phone:718-235-1087
Practice Address - Fax:718-235-1291
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307413-1163W00000X
NYF301322-1363LA2200X
NYF390021-1363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health