Healthcare Provider Details

I. General information

NPI: 1053740639
Provider Name (Legal Business Name): PAMELA GARDIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2013
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 MADISON AVE STE E
MORRISTOWN NJ
07960-6092
US

IV. Provider business mailing address

39 ESTE PL
BLOOMFIELD NJ
07003-4120
US

V. Phone/Fax

Practice location:
  • Phone: 973-285-7613
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00153400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: