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General NPI Number Information
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NPI Number | 1467972612
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Entity Type | Individual
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Provider Name | MAGDIEL LENIN FUENTES FUNEZ PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/20/2017
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Last Update Date | 01/03/2025
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Provider Practice Location Address
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Address Line | 350 ENGLE ST FL 5
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City | ENGLEWOOD
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State | NJ
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Zip | 07631-1808
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Country | US
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Telephone | 201-894-3636
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Fax |
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Provider Business Mailing Address
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Address Line | 331 NEWMAN SPRINGS RD STE 220
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City | RED BANK
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State | NJ
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Zip | 07701-5792
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Country | US
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Telephone | 732-807-0877
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3083
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License Number State | SC
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Taxonomy #2
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 25MP00577200
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | PA54487
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 25MP00577200
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License Number State | NJ
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Taxonomy #5
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA54487
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License Number State | CA
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