Healthcare Provider Details

I. General information

NPI: 1164260659
Provider Name (Legal Business Name): JOHN ANGELO PLACCA PA; ATC; LAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2024
Last Update Date: 07/18/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 NJ-17 SUITE 101
PARAMUS NJ
07652
US

IV. Provider business mailing address

225 N 21ST ST
KENILWORTH NJ
07033-1207
US

V. Phone/Fax

Practice location:
  • Phone: 844-777-0910
  • Fax:
Mailing address:
  • Phone: 908-578-9623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00213000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: