Provider Demographics
NPI:1770226821
Name:KURIEN, ROSHAN VARGHESE (PA-C)
Entity Type:Individual
Prefix:
First Name:ROSHAN
Middle Name:VARGHESE
Last Name:KURIEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:FLORAL PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11001-1639
Mailing Address - Country:US
Mailing Address - Phone:516-776-3103
Mailing Address - Fax:
Practice Address - Street 1:57190 MAIN RD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971-4750
Practice Address - Country:US
Practice Address - Phone:631-626-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-17
Last Update Date:2022-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1186411363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty