Healthcare Provider Details

I. General information

NPI: 1659568954
Provider Name (Legal Business Name): KISHORE KUPPASANI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S ORANGE AVE UH, H-346
NEWARK NJ
07103-2757
US

IV. Provider business mailing address

38 PARK ST UNIT-4E
FLORHAM PARK NJ
07932-1794
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-5283
  • Fax:
Mailing address:
  • Phone: 973-966-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00184900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: