Healthcare Provider Details

I. General information

NPI: 1174299549
Provider Name (Legal Business Name): KHALED RADY APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2021
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CAPITAL WAY STE 487
PENNINGTON NJ
08534-2521
US

IV. Provider business mailing address

2 CAPITAL WAY STE 487
PENNINGTON NJ
08534-2521
US

V. Phone/Fax

Practice location:
  • Phone: 609-818-1900
  • Fax:
Mailing address:
  • Phone: 609-818-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number26NJ01186700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: