Healthcare Provider Details

I. General information

NPI: 1427033356
Provider Name (Legal Business Name): LAUREN M CANOVA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN M GARETANO PA

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 PROFESSIONAL CIRCLE SUITE 101
COLTS NECK NJ
07722-2427
US

IV. Provider business mailing address

9 PROFESSIONAL CIR SUITE 101
COLTS NECK NJ
07722-2427
US

V. Phone/Fax

Practice location:
  • Phone: 732-431-1520
  • Fax:
Mailing address:
  • Phone: 732-431-1520
  • Fax: 732-431-1567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number010022
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP000305900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: