Healthcare Provider Details

I. General information

NPI: 1639371628
Provider Name (Legal Business Name): LAURO LUCIO ROCHA APRN,BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2007
Last Update Date: 02/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 W SIDE AVE
JERSEY CITY NJ
07304-1618
US

IV. Provider business mailing address

562 W SIDE AVE
JERSEY CITY NJ
07304-1618
US

V. Phone/Fax

Practice location:
  • Phone: 201-434-7800
  • Fax: 201-434-6715
Mailing address:
  • Phone: 201-434-7800
  • Fax: 201-434-6715

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00133200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: