Healthcare Provider Details

I. General information

NPI: 1740703206
Provider Name (Legal Business Name): COLLEEN PATRICIA JOSEPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2017
Last Update Date: 07/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

504 VALLEY RD
WAYNE NJ
07470-3534
US

IV. Provider business mailing address

80 SMULL AVE
WEST CALDWELL NJ
07006-7926
US

V. Phone/Fax

Practice location:
  • Phone: 973-694-2690
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00435400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number25MP00435400
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00435400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: