Healthcare Provider Details

I. General information

NPI: 1619996402
Provider Name (Legal Business Name): MICHAEL J CISKOWSKI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4810 BELMAR BLVD
WALL TOWNSHIP NJ
07753-6952
US

IV. Provider business mailing address

2 WORLDS FAIR DR
SOMERSET NJ
08873-1369
US

V. Phone/Fax

Practice location:
  • Phone: 732-938-6090
  • Fax: 732-938-5680
Mailing address:
  • Phone: 732-537-0909
  • Fax: 732-564-9032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001569
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00193800
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00193800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: