Healthcare Provider Details

I. General information

NPI: 1679167977
Provider Name (Legal Business Name): MG PHYSICIAN ASSISTANT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 SMITH PL APT 1
RIDGEWOOD NJ
07450-1402
US

IV. Provider business mailing address

414 SMITH PL APT 1
RIDGEWOOD NJ
07450-1402
US

V. Phone/Fax

Practice location:
  • Phone: 917-679-2200
  • Fax:
Mailing address:
  • Phone: 917-679-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MARIGONA GASHI
Title or Position: OWNER
Credential:
Phone: 917-679-2200