Healthcare Provider Details

I. General information

NPI: 1174719934
Provider Name (Legal Business Name): KERON A SINCLAIR PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2007
Last Update Date: 04/18/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 NO WASHINGTON AVE
GREEN BROOK NJ
08812
US

IV. Provider business mailing address

155 CODDINGTON AVE
SOMERSET NJ
08873-3453
US

V. Phone/Fax

Practice location:
  • Phone: 732-968-8900
  • Fax: 732-968-5607
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MP00186000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00186000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: