Healthcare Provider Details

I. General information

NPI: 1205087202
Provider Name (Legal Business Name): LUCY TASHAROFI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2008
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1255 RARITAN RD
CLARK NJ
07066-1200
US

IV. Provider business mailing address

1 DIAMOND HILL RD
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 848-206-0072
  • Fax: 848-206-0078
Mailing address:
  • Phone: 908-273-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00091100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: