Healthcare Provider Details

I. General information

NPI: 1326489477
Provider Name (Legal Business Name): KRISTEN LYNN CAUTILLI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 08/08/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 CENTER ST FL 2
SOMERS POINT NJ
08244-1802
US

IV. Provider business mailing address

1 E. NEW YORK AVE 4TH FLOOR ADMIN
SOMERS POINT NJ
08244-1520
US

V. Phone/Fax

Practice location:
  • Phone: 609-365-6280
  • Fax:
Mailing address:
  • Phone: 609-653-3265
  • Fax: 609-926-4311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA056182
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberOA003062
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00311200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: