MEDICARE: ANTONELLA F VITERBO MS,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	25MP00178900	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	223777917	OTHER	NJ	COMMERCIAL INSURANCES

General Provider Information

NPI Number	:	1760698617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANTONELLA F VITERBO MS,PA-C

Provider Business Mailing Address
First Line	:	20 MAXIM COURT
Second Line	:
City	:	JACKSON
State	:	NJ
Zip	:	08527
Country	:	US
Telephone Number	:	215-584-6731
Fax Number	:

Provider Business Practice Location Address
First Line	:	135 KINNELON RD RM 103
Second Line	:
City	:	KINNELON
State	:	NJ
Zip	:	07405-2333
Country	:	US
Telephone Number	:	973-838-1771
Fax Number	:	973-492-2858

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

Provider Enumeration Date	:	05/15/2007
Last Update Date	:	05/11/2021

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