Healthcare Provider Details

I. General information

NPI: 1003557422
Provider Name (Legal Business Name): KATHRYN BAGNARDI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PLUM ST FL 5
NEW BRUNSWICK NJ
08901-2066
US

IV. Provider business mailing address

200 TILTON RD STE 5
NORTHFIELD NJ
08225-1270
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-5530
  • Fax:
Mailing address:
  • Phone: 609-400-3910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00746100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: