Provider Demographics
NPI:1700280146
Name:ROMAN, EMILY DESTEFANO (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:DESTEFANO
Last Name:ROMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 POST RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6038
Mailing Address - Country:US
Mailing Address - Phone:203-255-8827
Mailing Address - Fax:203-259-4610
Practice Address - Street 1:1300 POST RD
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6038
Practice Address - Country:US
Practice Address - Phone:203-255-8827
Practice Address - Fax:203-259-4610
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT003217363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant