Provider Demographics
NPI:1740282508
Name:DEROSA, MARIA A (RPAC)
Entity type:Individual
Prefix:MS
First Name:MARIA
Middle Name:A
Last Name:DEROSA
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N UNION ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14607-1345
Mailing Address - Country:US
Mailing Address - Phone:585-232-8940
Mailing Address - Fax:585-232-8687
Practice Address - Street 1:730 WEILAND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-3919
Practice Address - Country:US
Practice Address - Phone:585-730-9600
Practice Address - Fax:585-719-9872
Is Sole Proprietor?:No
Enumeration Date:2005-08-11
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009407-1207NS0135X
NY0094071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPA0520Medicare ID - Type UnspecifiedMEDICARE NUMBER
NYP97681Medicare UPIN