Healthcare Provider Details

I. General information

NPI: 1477593820
Provider Name (Legal Business Name): IVAN BILBAO-LAVIEJA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W ESSEX ST STE 201
MAYWOOD NJ
07607-1023
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD BLDG 2, STE 220
RED BANK NJ
07701-5688
US

V. Phone/Fax

Practice location:
  • Phone: 201-251-7725
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00179900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number009941
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: