Healthcare Provider Details

I. General information

NPI: 1497781140
Provider Name (Legal Business Name): JOHN-ERIC VALLARTA CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 10/19/2022
Certification Date: 10/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BAY AVENUE MOUNTAINSIDE MEDICAL CENTER
MONTCLAIR NJ
07042
US

IV. Provider business mailing address

8 PINE TREE DR
WAYNE NJ
07470-5426
US

V. Phone/Fax

Practice location:
  • Phone: 973-429-6000
  • Fax:
Mailing address:
  • Phone: 732-236-1772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number5116A
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NJ00341600
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26N011136700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: