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General NPI Number Information
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NPI Number | 1043554512
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Entity Type | Individual
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Provider Name | IWONA PEDATELLA PA-C
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Gender | Female
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Dates
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Enumeration Date | 11/21/2012
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Last Update Date | 11/21/2012
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Provider Practice Location Address
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Address Line | 221 W GRAND AVE
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City | MONTVALE
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State | NJ
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Zip | 07645-1729
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Country | US
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Telephone | 201-307-0075
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Fax |
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Provider Business Mailing Address
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Address Line | 4000 RIVERDALE RD 402
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City | RIVERDALE
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State | NJ
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Zip | 07457-1729
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Country | US
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Telephone | 973-896-1344
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 25MP00290300
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License Number State | NJ
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