Healthcare Provider Details

I. General information

NPI: 1639699713
Provider Name (Legal Business Name): NICOLE LUPO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2017
Last Update Date: 06/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 MONMOUTH RD
OAKHURST NJ
07755-1515
US

IV. Provider business mailing address

10 CRIMSON LN
FREEHOLD NJ
07728-9013
US

V. Phone/Fax

Practice location:
  • Phone: 732-531-5445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MP00434000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: