Healthcare Provider Details

I. General information

NPI: 1902057284
Provider Name (Legal Business Name): JOYCE E SAMUEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

385 PROSPECT AVE
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

385 PROSPECT AVE
HACKENSACK NJ
07601-2570
US

V. Phone/Fax

Practice location:
  • Phone: 201-646-1121
  • Fax: 201-646-1110
Mailing address:
  • Phone: 201-646-1121
  • Fax: 201-646-1110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00204200
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: