Healthcare Provider Details

I. General information

NPI: 1689680779
Provider Name (Legal Business Name): ROXANNE SMITH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOLLYWOOD AVE
HILLSIDE NJ
07205-2409
US

IV. Provider business mailing address

100 HOLLYWOOD AVE HILLSIDE FAMILY PRACTICE
HILLSIDE NJ
07205-2409
US

V. Phone/Fax

Practice location:
  • Phone: 908-353-7949
  • Fax: 908-353-8374
Mailing address:
  • Phone: 908-353-7949
  • Fax: 908-353-8374

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00086300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: