Healthcare Provider Details

I. General information

NPI: 1811704513
Provider Name (Legal Business Name): MARTIN FAQUAN ESCOURSE SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 OBRIEN ST UNIT E7
KEARNY NJ
07032-4212
US

IV. Provider business mailing address

216 ASTORIA PL
UNION NJ
07083-4208
US

V. Phone/Fax

Practice location:
  • Phone: 732-231-5273
  • Fax: 732-860-9883
Mailing address:
  • Phone: 732-231-5273
  • Fax: 732-860-9883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: