Healthcare Provider Details

I. General information

NPI: 1114159506
Provider Name (Legal Business Name): MRS. VASHTI ETWARU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

649 MORRIS AVE
SPRINGFIELD NJ
07081-1526
US

IV. Provider business mailing address

22 CROWN VIEW CT
SPARTA NJ
07871-3569
US

V. Phone/Fax

Practice location:
  • Phone: 973-795-7955
  • Fax:
Mailing address:
  • Phone: 516-343-5339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number013232
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: