Basic Information
| Provider Information | |||||||||
| NPI: | 1811408313 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOOTH | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | TYLER | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 39 CEDAR GROVE PKWY | ||||||||
| Address2: | |||||||||
| City: | CEDAR GROVE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070091405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737380627 | ||||||||
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| Practice Location | |||||||||
| Address1: | 784 FRANKLIN AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN LAKES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074171306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8447770910 | ||||||||
| FaxNumber: | 2015600712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2017 | ||||||||
| LastUpdateDate: | 11/02/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00452000 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.