Healthcare Provider Details

I. General information

NPI: 1558369363
Provider Name (Legal Business Name): PATRICK A ERVILUS NPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 08/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 RIVER RD
CAMDEN NJ
08105-4426
US

IV. Provider business mailing address

405 W COUNTRY CLUB DR
WESTAMPTON NJ
08060-4741
US

V. Phone/Fax

Practice location:
  • Phone: 856-966-8088
  • Fax: 856-966-8089
Mailing address:
  • Phone: 609-702-5808
  • Fax: 609-702-5809

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NN10322000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NN10322000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: