Healthcare Provider Details

I. General information

NPI: 1689409054
Provider Name (Legal Business Name): BRYAN BOLANOSGONZALEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2024
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 ARCADIAN WAY STE C2
PARAMUS NJ
07652-1291
US

IV. Provider business mailing address

429-4 STATE ROUTE 31 S
WASHINGTON NJ
07882-4182
US

V. Phone/Fax

Practice location:
  • Phone: 908-271-8368
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR19503300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ15345000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: