Healthcare Provider Details

I. General information

NPI: 1215245204
Provider Name (Legal Business Name): MANUEL ANTONIO PATUSCO APN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 04/02/2021
Certification Date: 04/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PLUM ST FL 8
NEW BRUNSWICK NJ
08901-2066
US

IV. Provider business mailing address

10 PLUM ST 8 TH FLOOR
NEW BRUNSWICK NJ
08901-2065
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00303800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: