Healthcare Provider Details

I. General information

NPI: 1366363152
Provider Name (Legal Business Name): BREONA ALEXIS MACK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 HOES LN W
PISCATAWAY NJ
08854-8021
US

IV. Provider business mailing address

304 S 10TH AVE APT C
HIGHLAND PARK NJ
08904-3410
US

V. Phone/Fax

Practice location:
  • Phone: 732-235-4445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: