Healthcare Provider Details

I. General information

NPI: 1831594944
Provider Name (Legal Business Name): GAETANO L CAMBRIA PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N 39TH ST
PHILADELPHIA PA
19104
US

IV. Provider business mailing address

3600 ROUTE 66 3RD FL
NEPTUNE NJ
07753-2645
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-9493
  • Fax:
Mailing address:
  • Phone: 732-807-0880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00417600
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA059672
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00417600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: