Healthcare Provider Details

I. General information

NPI: 1104347541
Provider Name (Legal Business Name): ADRIANA DUDECK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 09/24/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2107 STATE ROUTE 35
HOLMDEL NJ
07733-2795
US

IV. Provider business mailing address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

V. Phone/Fax

Practice location:
  • Phone: 732-587-5065
  • Fax:
Mailing address:
  • Phone: 516-869-0650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00439900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: