Basic Information
| Provider Information | |||||||||
| NPI: | 1841916137 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROMAN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSN, NP, CVRN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 64 SILVER ST | ||||||||
| Address2: | |||||||||
| City: | WEST BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117043925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313832070 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1000 MONTAUK HWY | ||||||||
| Address2: | |||||||||
| City: | WEST ISLIP | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117954927 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313763000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2022 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | F310969 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.