Provider Demographics
NPI:1417998725
Name:ROSSANO, MATTHEW (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:ROSSANO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3917
Mailing Address - Country:US
Mailing Address - Phone:718-448-4488
Mailing Address - Fax:718-442-4874
Practice Address - Street 1:1324 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3917
Practice Address - Country:US
Practice Address - Phone:718-448-4488
Practice Address - Fax:718-442-4874
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009267-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2874434171Medicare PIN