=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467661140
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADENA TARA HOMNICK RPA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 150 BERGEN ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07103-2496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-972-4900
-----------------------------------------------------
Fax | 973-972-7441
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5 N CREST PL
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08701-2967
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-886-2997
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 25MP00034600
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------