Healthcare Provider Details

I. General information

NPI: 1487822193
Provider Name (Legal Business Name): NECHAMA BRODT PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 04/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 2ND AVE
LONG BRANCH NJ
07740-6303
US

IV. Provider business mailing address

1518 LONG BEACH AVE
LAKEWOOD NJ
08701-3855
US

V. Phone/Fax

Practice location:
  • Phone: 732-923-7389
  • Fax:
Mailing address:
  • Phone: 732-901-1537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00192300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: