Healthcare Provider Details

I. General information

NPI: 1669024378
Provider Name (Legal Business Name): LAUREN ELIZABETH PETRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

571 W MOUNT PLEASANT AVE
LIVINGSTON NJ
07039-1607
US

IV. Provider business mailing address

51 MORRIS PL APT 2
BLOOMFIELD NJ
07003-3768
US

V. Phone/Fax

Practice location:
  • Phone: 973-992-4767
  • Fax:
Mailing address:
  • Phone: 860-707-5720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00532800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: