Healthcare Provider Details

I. General information

NPI: 1710256425
Provider Name (Legal Business Name): HEATHER KOTUSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2011
Last Update Date: 07/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 WILLOW AVE
HOBOKEN NJ
07030-3808
US

IV. Provider business mailing address

308 WILLOW AVE
HOBOKEN NJ
07030-3808
US

V. Phone/Fax

Practice location:
  • Phone: 201-418-1900
  • Fax:
Mailing address:
  • Phone: 201-418-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00275500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: