Healthcare Provider Details

I. General information

NPI: 1972586642
Provider Name (Legal Business Name): GARY ALAN FALCETANO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2005
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 EDNA HORN DR
STOCKTON NJ
08559-1401
US

IV. Provider business mailing address

4 EDNA HORN DR
STOCKTON NJ
08559-1401
US

V. Phone/Fax

Practice location:
  • Phone: 609-773-0559
  • Fax:
Mailing address:
  • Phone: 609-773-0559
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00044300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: