Basic Information
| Provider Information | |||||||||
| NPI: | 1619497658 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ANTONUCCI | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 MEMORIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070034266 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 CLARA MAASS DR | ||||||||
| Address2: | |||||||||
| City: | BELLEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734502000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2017 | ||||||||
| LastUpdateDate: | 07/26/2018 | ||||||||
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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 | 363A00000X | 25MP00437300 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.