Healthcare Provider Details

I. General information

NPI: 1972877371
Provider Name (Legal Business Name): PAULINE TYAS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4065 QUAKERBRIDGE RD
PRINCETON JCT NJ
08550
US

IV. Provider business mailing address

1 WATERWORKS RD
FREEHOLD NJ
07728-4231
US

V. Phone/Fax

Practice location:
  • Phone: 609-651-4001
  • Fax:
Mailing address:
  • Phone: 732-866-3665
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ00346300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: