Healthcare Provider Details

I. General information

NPI: 1154750990
Provider Name (Legal Business Name): BRYAN BOCCO APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2013
Last Update Date: 12/31/2025
Certification Date: 12/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 HAMBURG TPKE
WAYNE NJ
07470-6226
US

IV. Provider business mailing address

47 STARLITE DR
CLARK NJ
07066-2926
US

V. Phone/Fax

Practice location:
  • Phone: 973-839-3400
  • Fax:
Mailing address:
  • Phone: 732-259-2593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00471600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: