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General NPI Number Information
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NPI Number | 1083067722
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Entity Type | Individual
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Provider Name | MARYJO AGOSTA
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Gender | Female
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Dates
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Enumeration Date | 07/18/2016
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Last Update Date | 07/18/2016
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Provider Practice Location Address
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Address Line | 1000 GALLOPING HILL RD
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City | UNION
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State | NJ
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Zip | 07083-7989
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Country | US
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Telephone | 908-522-6300
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Fax |
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Provider Business Mailing Address
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Address Line | 30 ROOSEVELT AVE
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City | CHATHAM
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State | NJ
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Zip | 07928-2548
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Country | US
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Telephone |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 25MP00403100
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License Number State | NJ
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