Healthcare Provider Details

I. General information

NPI: 1700577418
Provider Name (Legal Business Name): SUZANNE DORA WOLLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 GALWAY PL STE 300
TEANECK NJ
07666-3640
US

IV. Provider business mailing address

111 GALWAY PL STE 300
TEANECK NJ
07666-3640
US

V. Phone/Fax

Practice location:
  • Phone: 201-833-9500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: