Healthcare Provider Details

I. General information

NPI: 1619795432
Provider Name (Legal Business Name): IGOR WATANABE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 LAFAYETTE ST FL 3
NEWARK NJ
07105-7601
US

IV. Provider business mailing address

263 LAFAYETTE ST
NEWARK NJ
07105-7600
US

V. Phone/Fax

Practice location:
  • Phone: 973-344-5379
  • Fax: 973-344-1988
Mailing address:
  • Phone: 978-302-8684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ15626500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: