Healthcare Provider Details

I. General information

NPI: 1942826458
Provider Name (Legal Business Name): KRISTINA MARIE DAUERNHEIM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2020
Last Update Date: 10/09/2020
Certification Date: 10/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 DAVIS AVE 4TH FLOOR HOPE TOWER
NEPTUNE NJ
07753
US

IV. Provider business mailing address

19 DAVIS AVE 4TH FLOOR HOPE TOWER
NEPTUNE NJ
07753
US

V. Phone/Fax

Practice location:
  • Phone: 732-974-0003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MP00582200
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00582200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: