Healthcare Provider Details

I. General information

NPI: 1851805741
Provider Name (Legal Business Name): DOMENICO COLLETTI JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 NJ 35
WALL NJ
07719
US

IV. Provider business mailing address

1930 NJ 35
WALL NJ
08077-3534
US

V. Phone/Fax

Practice location:
  • Phone: 732-456-7777
  • Fax: 732-455-1104
Mailing address:
  • Phone: 732-456-7777
  • Fax: 732-455-1104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00450700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: