Healthcare Provider Details

I. General information

NPI: 1588181713
Provider Name (Legal Business Name): FRED LWAKAAKA APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

281 MATHISTOWN RD
LITTLE EGG HARBOR TWP NJ
08087-4066
US

IV. Provider business mailing address

61 ASHLEY DR
FRANKLINVILLE NJ
08322-2686
US

V. Phone/Fax

Practice location:
  • Phone: 609-857-4141
  • Fax:
Mailing address:
  • Phone: 732-986-3486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ00731800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: