Healthcare Provider Details

I. General information

NPI: 1376291013
Provider Name (Legal Business Name): ANDRE AUGUSTIN APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 BLOOMFIELD AVE STE F
BLOOMFIELD NJ
07003-5902
US

IV. Provider business mailing address

55 A LINN DR
VERONA NJ
07044
US

V. Phone/Fax

Practice location:
  • Phone: 862-213-0033
  • Fax: 862-213-0037
Mailing address:
  • Phone: 973-641-0353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number26NJ01282100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ01282100
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier26NJ01282100
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNP

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: