Healthcare Provider Details

I. General information

NPI: 1477230308
Provider Name (Legal Business Name): SAMANTHA RYLLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S ORANGE AVE STE 102
LIVINGSTON NJ
07039-5817
US

IV. Provider business mailing address

379 CAMPUS DR FL 4
SOMERSET NJ
08873-1161
US

V. Phone/Fax

Practice location:
  • Phone: 973-322-7020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00876300
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number030278
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: