Healthcare Provider Details

I. General information

NPI: 1023848017
Provider Name (Legal Business Name): MICHAEL JIN BACK RN, BSN, MSN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 PROSPECT AVE APT 3G
HACKENSACK NJ
07601-1857
US

IV. Provider business mailing address

170 PROSPECT AVE APT 3G
HACKENSACK NJ
07601-1857
US

V. Phone/Fax

Practice location:
  • Phone: 201-577-8494
  • Fax:
Mailing address:
  • Phone: 201-577-8494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NR15265100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: