Basic Information
| Provider Information | |||||||||
| NPI: | 1730211145 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEROSE | ||||||||
| FirstName: | TROY | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNP, RNFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16 INDIAN HILL LN | ||||||||
| Address2: | |||||||||
| City: | SICKLERVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080811731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567401727 | ||||||||
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| Practice Location | |||||||||
| Address1: | 925 CHESTNUT ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159556760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP007949 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 103069397 | 05 | PA | MEDICAID |