Healthcare Provider Details

I. General information

NPI: 1831593961
Provider Name (Legal Business Name): ISLAM KASSAB PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 09/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 MAIN STREET
PATERSON NJ
07503
US

IV. Provider business mailing address

128 LEONARD ST
JERSEY CITY NJ
07307-3102
US

V. Phone/Fax

Practice location:
  • Phone: 973-754-2486
  • Fax: 973-754-2975
Mailing address:
  • Phone: 201-780-9487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00354100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: