Basic Information
| Provider Information | |||||||||
| NPI: | 1104958909 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FROMMER | ||||||||
| FirstName: | AVIVA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSENBLUM | ||||||||
| OtherFirstName: | AVIVA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 31 PENNINGTON WAY | ||||||||
| Address2: | |||||||||
| City: | NEW HEMPSTEAD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109771418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453620527 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 70 HATFIELD LN | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452911260 | ||||||||
| FaxNumber: | 8452942312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 10/02/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 011742 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 029400 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.