Provider Demographics
NPI:1952797151
Name:ROMAN, WANDA
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:ROMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2454 TIEBOUT AVE
Mailing Address - Street 2:APT. 3A
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-5413
Mailing Address - Country:US
Mailing Address - Phone:954-682-5095
Mailing Address - Fax:
Practice Address - Street 1:2454 TIEBOUT AVE
Practice Address - Street 2:APT. 3A
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-5413
Practice Address - Country:US
Practice Address - Phone:954-682-5095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY836064174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist