Basic Information
Provider Information | |||||||||
NPI: | 1851677678 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAMMANO | ||||||||
FirstName: | JOSEPH | ||||||||
MiddleName: | DANIEL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHYSICIAN ASSISTANT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 925 CHESTNUT ST | ||||||||
Address2: | FL 5 | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8003219999 | ||||||||
FaxNumber: | 2673393761 | ||||||||
Practice Location | |||||||||
Address1: | 611 NEW RD | ||||||||
Address2: |   | ||||||||
City: | NORTHFIELD | ||||||||
State: | NJ | ||||||||
PostalCode: | 082251669 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096451500 | ||||||||
FaxNumber: | 6096258245 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/25/2011 | ||||||||
LastUpdateDate: | 02/25/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 25MP00270300 | NJ | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.