Healthcare Provider Details

I. General information

NPI: 1396095204
Provider Name (Legal Business Name): MICHELLE JOSEPH PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 PROSPECT AVE
HACKENSACK NJ
07601-1960
US

IV. Provider business mailing address

25 PROSPECT AVENUE
HACKENSACK NJ
07601
US

V. Phone/Fax

Practice location:
  • Phone: 201-904-2325
  • Fax: 201-343-7410
Mailing address:
  • Phone: 201-487-4600
  • Fax: 201-343-7410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00287400
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: