Healthcare Provider Details

I. General information

NPI: 1518368257
Provider Name (Legal Business Name): BILAL BAJWA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 N WASHINGTON AVE
GREEN BROOK NJ
08812-2619
US

IV. Provider business mailing address

1005 N WASHINGTON AVE
GREEN BROOK NJ
08812-2619
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00346500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: