Provider Demographics
NPI:1760700843
Name:RODRIGUEZ, AZALESHA ABRAHIM (MS PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AZALESHA
Middle Name:ABRAHIM
Last Name:RODRIGUEZ
Suffix:
Gender:F
Credentials:MS PA-C
Other - Prefix:
Other - First Name:AZALESHA
Other - Middle Name:
Other - Last Name:ABRAHIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS PA-C
Mailing Address - Street 1:1855 RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3940
Mailing Address - Country:US
Mailing Address - Phone:718-697-2212
Mailing Address - Fax:
Practice Address - Street 1:1855 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3940
Practice Address - Country:US
Practice Address - Phone:718-697-2212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY25MP00232600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant