Basic Information
| Provider Information | |||||||||
| NPI: | 1063573095 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PRATT | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ROBERT WOOD JOHNSON PL | ||||||||
| Address2: | ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL - NEW BRUNSWICK | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322357044 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 02/04/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | 25MA076897 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8776601 | 05 | NJ | MEDICAID |