Healthcare Provider Details

I. General information

NPI: 1275318743
Provider Name (Legal Business Name): DANIEL FALDRAGA MMS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 ROUTE 66 STE 400
NEPTUNE NJ
07753-2645
US

IV. Provider business mailing address

707 N BROAD ST APT 3G
ELIZABETH NJ
07208-2317
US

V. Phone/Fax

Practice location:
  • Phone: 732-363-6655
  • Fax:
Mailing address:
  • Phone: 908-414-8208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00812800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: