Basic Information
| Provider Information | |||||||||
| NPI: | 1720415086 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCTIGUE | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KOCHER | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 315 STATE ROUTE 31 S | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078824069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088473100 | ||||||||
| FaxNumber: | 8662769292 | ||||||||
| Practice Location | |||||||||
| Address1: | 315 STATE ROUTE 31 S | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 078824069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088473100 | ||||||||
| FaxNumber: | 8662769292 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2013 | ||||||||
| LastUpdateDate: | 09/30/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | SP013222 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0451649 | 05 | NJ | MEDICAID |