Healthcare Provider Details

I. General information

NPI: 1962945030
Provider Name (Legal Business Name): MEREDITH GARDNER PA-C, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEREDITH FECSKOVICS

II. Dates (important events)

Enumeration Date: 11/22/2016
Last Update Date: 11/06/2023
Certification Date: 11/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 FROM RD
PARAMUS NJ
07652-3517
US

IV. Provider business mailing address

3600 ROUTE 66 FL 3
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 201-639-6620
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00639700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: