Healthcare Provider Details

I. General information

NPI: 1780960542
Provider Name (Legal Business Name): JOHN RICHARD ALBANESE III PA-C, MPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 973-996-5492
  • Fax:
Mailing address:
  • Phone: 973-996-5492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00274600
License Number StateNJ

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: