Provider Demographics
NPI:1134769920
Name:RAMKISSOON, ROLAND JOHNATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:ROLAND
Middle Name:JOHNATHAN
Last Name:RAMKISSOON
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 1:855 MONTAUK HWY STE A
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-2153
Mailing Address - Country:US
Mailing Address - Phone:631-815-1958
Mailing Address - Fax:631-772-3910
Practice Address - Street 1:855 MONTAUK HWY STE A
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-2153
Practice Address - Country:US
Practice Address - Phone:631-815-1958
Practice Address - Fax:631-772-3910
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY026676363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program