MEDICARE: NANDANEE MYNENI PA-C

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	363A00000X	Physician Assistant	25MP00178400	NJ

General Provider Information

NPI Number	:	1487872131
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANDANEE MYNENI PA-C

Provider Business Mailing Address
First Line	:	600 PAVONIA AVE
Second Line	:
City	:	JERSEY CITY
State	:	NJ
Zip	:	07306-2929
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	824 ELIZABETH AVE
Second Line	:
City	:	ELIZABETH
State	:	NJ
Zip	:	07201-4708
Country	:	US
Telephone Number	:	908-352-9556
Fax Number	:

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

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	05/19/2021

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