Healthcare Provider Details

I. General information

NPI: 1487312898
Provider Name (Legal Business Name): EDWIN ROQUE APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

65 W JIMMIE LEEDS RD
POMONA NJ
08240-9102
US

IV. Provider business mailing address

27 ABINGTON CT
MAYS LANDING NJ
08330-1939
US

V. Phone/Fax

Practice location:
  • Phone: 609-652-1000
  • Fax:
Mailing address:
  • Phone: 609-553-6692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number26NJ01169900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: