Healthcare Provider Details

I. General information

NPI: 1124655022
Provider Name (Legal Business Name): JUSTIN YAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2020
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ENGLE ST
ENGLEWOOD NJ
07631-1808
US

IV. Provider business mailing address

187 HIGHWAY 36 STE 230
WEST LONG BRANCH NJ
07764-1306
US

V. Phone/Fax

Practice location:
  • Phone: 201-894-3000
  • Fax:
Mailing address:
  • Phone: 732-702-1039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA12057400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: