MEDICARE: MRS. PUSHPAM MARY WILLIAM NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	26NJ00324000	NJ

General Provider Information

NPI Number	:	1295165777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PUSHPAM MARY WILLIAM NP

Provider Business Mailing Address
First Line	:	111 DELMONICO AVE
Second Line	:
City	:	SOMERSET
State	:	NJ
Zip	:	08873-3410
Country	:	US
Telephone Number	:	973-704-5202
Fax Number	:

Provider Business Practice Location Address
First Line	:	719 ROUTE 22 W
Second Line	:
City	:	NORTH PLAINFIELD
State	:	NJ
Zip	:	07060-4924
Country	:	US
Telephone Number	:	908-561-4300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2013
Last Update Date	:	11/19/2013

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