Provider Demographics
NPI:1790957678
Name:STA ROSA, RODERICK GAMBOA (PT)
Entity Type:Individual
Prefix:
First Name:RODERICK
Middle Name:GAMBOA
Last Name:STA ROSA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4175 VETERANS MEMORIAL HWY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7639
Mailing Address - Country:US
Mailing Address - Phone:631-580-5200
Mailing Address - Fax:631-580-5222
Practice Address - Street 1:303 W MAIN ST
Practice Address - Street 2:SUITE B18
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-4832
Practice Address - Country:US
Practice Address - Phone:732-431-8900
Practice Address - Fax:732-431-0244
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00417800225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist