Healthcare Provider Details

I. General information

NPI: 1912507641
Provider Name (Legal Business Name): KATHERINE BADECKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 04/08/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 S WHITE HORSE PIKE
WATERFORD WORKS NJ
08089
US

IV. Provider business mailing address

30 BEAMS TER
MANASQUAN NJ
08736-2905
US

V. Phone/Fax

Practice location:
  • Phone: 609-561-5900
  • Fax:
Mailing address:
  • Phone: 732-804-9506
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: