Healthcare Provider Details

I. General information

NPI: 1477905925
Provider Name (Legal Business Name): GINA MARIE MIRANDA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA MARIE MATTIELLO PA-C

II. Dates (important events)

Enumeration Date: 07/08/2016
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FEDERAL CITY RD
LAWRENCEVILLE NJ
08648-1664
US

IV. Provider business mailing address

8 GORHAM CT
JACKSON NJ
08527-6324
US

V. Phone/Fax

Practice location:
  • Phone: 609-620-1380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00399000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: