Healthcare Provider Details

I. General information

NPI: 1174925911
Provider Name (Legal Business Name): BROOKE HOTALING PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2014
Last Update Date: 08/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 PARK AVE
FLORHAM PARK NJ
07932
US

IV. Provider business mailing address

1220 NEW SCOTLAND RD SUITE 204
SLINGERLANDS NY
12159-9386
US

V. Phone/Fax

Practice location:
  • Phone: 973-404-9960
  • Fax: 973-267-0024
Mailing address:
  • Phone: 518-439-4326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number018034
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00484900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: