=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881677599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YEVGENIYA DREIZIN PHYSICIANS ASSISTANT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 901 W MAIN ST # 103
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-742-5084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 ROLLING HILL DR
-----------------------------------------------------
City | MORGANVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07751-2053
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-742-5084
-----------------------------------------------------
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 | 25MP00119800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------