Healthcare Provider Details

I. General information

NPI: 1538090576
Provider Name (Legal Business Name): SABREENA MOOSE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 ROUTE 23 STE 160
WAYNE NJ
07470-7512
US

IV. Provider business mailing address

17 BRYAN DR
MONTVALE NJ
07645-1401
US

V. Phone/Fax

Practice location:
  • Phone: 973-221-2500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number25MP01016000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: