Healthcare Provider Details

I. General information

NPI: 1467057935
Provider Name (Legal Business Name): THERESA C ESPOSITO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2020
Last Update Date: 05/25/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 N WASHINGTON AVE STE 203
BERGENFIELD NJ
07621-1776
US

IV. Provider business mailing address

56 WALNUT AVE
BELLMAWR NJ
08031-2222
US

V. Phone/Fax

Practice location:
  • Phone: 201-374-1718
  • Fax:
Mailing address:
  • Phone: 201-290-1954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00589300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: