Healthcare Provider Details

I. General information

NPI: 1033353933
Provider Name (Legal Business Name): NICOLE MARIE PANTANO D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2009
Last Update Date: 07/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BETHANY RD BUILDING 5, SUITE 65
HAZLET NJ
07730-1663
US

IV. Provider business mailing address

1 BETHANY RD BUILDING 5, SUITE 65
HAZLET NJ
07730-1663
US

V. Phone/Fax

Practice location:
  • Phone: 732-264-0700
  • Fax:
Mailing address:
  • Phone: 732-264-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB08570100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: