Healthcare Provider Details

I. General information

NPI: 1598405730
Provider Name (Legal Business Name): GENT PRELVUKAJ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 JACK MARTIN BLVD
BRICK NJ
08724-7732
US

IV. Provider business mailing address

182 JULES DR
STATEN ISLAND NY
10314-1433
US

V. Phone/Fax

Practice location:
  • Phone: 732-840-3380
  • Fax:
Mailing address:
  • Phone: 718-310-7686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00697200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: