Provider Demographics
NPI:1013098441
Name:BROWN, ROSELYN BURTON (PA-C)
Entity type:Individual
Prefix:MS
First Name:ROSELYN
Middle Name:BURTON
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7901 BROADWAY
Mailing Address - Street 2:MANAGED CARE, D1-01
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1329
Mailing Address - Country:US
Mailing Address - Phone:718-334-1921
Mailing Address - Fax:718-334-3432
Practice Address - Street 1:4153 LAWRENCEVILLE HWY NW
Practice Address - Street 2:SUITE 5
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2854
Practice Address - Country:US
Practice Address - Phone:470-514-4301
Practice Address - Fax:470-514-4306
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005961363A00000X
GA005245363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00330231Medicare ID - Type Unspecified
NY00246075Medicaid