Provider Demographics
NPI:1962470450
Name:ROGGENBURG, MARY PAT (FNP)
Entity Type:Individual
Prefix:MS
First Name:MARY PAT
Middle Name:
Last Name:ROGGENBURG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 RICHMOND TER
Mailing Address - Street 2:3F
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1501
Mailing Address - Country:US
Mailing Address - Phone:718-816-4764
Mailing Address - Fax:718-226-8102
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-6717
Practice Address - Fax:718-226-2450
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332121-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily