Healthcare Provider Details

I. General information

NPI: 1154164150
Provider Name (Legal Business Name): BRANTON SHPILEVSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

20-07 HUNTER PL
FAIR LAWN NJ
07410-5238
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-3192
  • Fax:
Mailing address:
  • Phone: 201-724-9119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: