Provider Demographics
NPI:1821176884
Name:DIRENY-JEAN, ROSE (PA)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:DIRENY-JEAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 HEMPSTEAD TPKE
Mailing Address - Street 2:BUILDING E -RM 247
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554-1859
Mailing Address - Country:US
Mailing Address - Phone:516-572-6506
Mailing Address - Fax:516-572-5648
Practice Address - Street 1:2201 HEMPSTEAD TPKE
Practice Address - Street 2:BUILDING E -RM 247
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554-1859
Practice Address - Country:US
Practice Address - Phone:516-572-6506
Practice Address - Fax:516-572-5648
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02243245Medicaid
NY970024027OtherRAILROAD
NY970024027OtherRAILROAD
NY0076QNMedicare ID - Type Unspecified
NY02243245Medicaid