Healthcare Provider Details

I. General information

NPI: 1083545297
Provider Name (Legal Business Name): HAZEL SUBA
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

875 5TH AVE # 1CDE
NEW YORK NY
10065-4952
US

IV. Provider business mailing address

39 S WILLIAMS ST
BERGENFIELD NJ
07621-2328
US

V. Phone/Fax

Practice location:
  • Phone: 201-699-7642
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: