Healthcare Provider Details

I. General information

NPI: 1780143107
Provider Name (Legal Business Name): SARAH N MYERS STUDENR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 POMPTON RD
WAYNE NJ
07470-2103
US

IV. Provider business mailing address

891 S OLDEN AVE
HAMILTON NJ
08610-5161
US

V. Phone/Fax

Practice location:
  • Phone: 973-720-2000
  • Fax:
Mailing address:
  • Phone: 609-414-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierU0813236004
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerCIGNA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: