Healthcare Provider Details

I. General information

NPI: 1801048103
Provider Name (Legal Business Name): AMANDA MAZZETTA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA TIRADO PA-C

II. Dates (important events)

Enumeration Date: 10/17/2008
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CENTRAL AVE
CLARK NJ
07066
US

IV. Provider business mailing address

1075 CENTRAL AVE
CLARK NJ
07066
US

V. Phone/Fax

Practice location:
  • Phone: 732-574-1399
  • Fax: 732-574-1433
Mailing address:
  • Phone: 732-574-1399
  • Fax: 732-574-1433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00208400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: