Healthcare Provider Details

I. General information

NPI: 1689663528
Provider Name (Legal Business Name): JAMES E. PATRICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 06/07/2022
Certification Date: 06/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

32507 HAWKS LAKE LN
SORRENTO FL
32776-7738
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5430
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9101332
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00691400
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier291312700
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 2
Identifier107788100
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: