Healthcare Provider Details

I. General information

NPI: 1639841935
Provider Name (Legal Business Name): ELIZABETH SGAMBELLURI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2021
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N WASHINGTON AVE
GREEN BROOK NJ
08812-2698
US

IV. Provider business mailing address

26 LOCUST DR APT 17
SUMMIT NJ
07901-4420
US

V. Phone/Fax

Practice location:
  • Phone: 732-968-8900
  • Fax:
Mailing address:
  • Phone: 484-553-3085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1187799
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00666600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: