Healthcare Provider Details

I. General information

NPI: 1023395902
Provider Name (Legal Business Name): LORENA M EGUEZ PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 11/29/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1829 HUDSON PARK
EDGEWATER NJ
07020-1575
US

IV. Provider business mailing address

22 GRAND COVE WAY
EDGEWATER NJ
07020-7222
US

V. Phone/Fax

Practice location:
  • Phone: 201-562-5523
  • Fax: 563-649-6013
Mailing address:
  • Phone: 201-422-0313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00265300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00265300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: