Healthcare Provider Details

I. General information

NPI: 1366332520
Provider Name (Legal Business Name): RAFFAELE CHARLES SIMONE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 08/08/2025
Certification Date: 08/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 N STATE RT 17 STE 2
HACKENSACK NJ
07601-1071
US

IV. Provider business mailing address

90 MATAWAN RD STE 302
MATAWAN NJ
07747-2653
US

V. Phone/Fax

Practice location:
  • Phone: 732-906-9600
  • Fax: 833-974-2196
Mailing address:
  • Phone: 732-441-7177
  • Fax: 732-441-7165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00955700
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: