Provider Demographics
NPI:1629190970
Name:ROMAN, ANN MARIE (NP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:ROMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2010
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4510
Mailing Address - Country:US
Mailing Address - Phone:315-472-7504
Mailing Address - Fax:315-479-8639
Practice Address - Street 1:5008 BRITTONFIELD PKWY
Practice Address - Street 2:SUITE 700
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:315-472-7504
Practice Address - Fax:315-479-8639
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302135363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02508767Medicaid
NYJ400066526Medicare PIN
RB3713Medicare PIN
NY02508767Medicaid
34589AMedicare PIN
NY00555440Medicaid
NY00555500Medicaid
50019AMedicare PIN