Healthcare Provider Details

I. General information

NPI: 1689277253
Provider Name (Legal Business Name): LAURA A DWECK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 BRICK BLVD
BRICK NJ
08723-6077
US

IV. Provider business mailing address

247 HIGHLAND AVE
LONG BRANCH NJ
07740-4620
US

V. Phone/Fax

Practice location:
  • Phone: 732-701-4848
  • Fax:
Mailing address:
  • Phone: 732-859-3372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00578800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: