Provider Demographics
NPI:1780710889
Name:GROGAN, DESIREE (PA)
Entity type:Individual
Prefix:MRS
First Name:DESIREE
Middle Name:
Last Name:GROGAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:GALLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:59 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-3138
Mailing Address - Country:US
Mailing Address - Phone:516-293-0898
Mailing Address - Fax:
Practice Address - Street 1:450 LAKEVILLE RD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1118
Practice Address - Country:US
Practice Address - Phone:516-734-8876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY006618363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ67330Medicare UPIN