Healthcare Provider Details

I. General information

NPI: 1659747947
Provider Name (Legal Business Name): ZEV PORTNOY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 08/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 RIVER AVE
LAKEWOOD NJ
08701-5646
US

IV. Provider business mailing address

1352 RIVER AVE
LAKEWOOD NJ
08701-5646
US

V. Phone/Fax

Practice location:
  • Phone: 732-370-5100
  • Fax:
Mailing address:
  • Phone: 732-370-5100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00372400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: