Healthcare Provider Details

I. General information

NPI: 1457672768
Provider Name (Legal Business Name): THEA COGAN-DREW PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 PARK AVE STE 3
PLAINFIELD NJ
07060-3253
US

IV. Provider business mailing address

18 W ELM ST
NEW HAVEN CT
06515-2129
US

V. Phone/Fax

Practice location:
  • Phone: 732-209-5638
  • Fax:
Mailing address:
  • Phone: 203-804-3714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00374800
License Number StateNJ

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: