Provider Demographics
NPI:1003595901
Name:FEDERICA, JAMES MANUEL
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MANUEL
Last Name:FEDERICA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 MANCHESTER WAY
Mailing Address - Street 2:
Mailing Address - City:PINE BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:07058-9553
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:170 CHANGEBRIDGE RD BLDG C3
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9112
Practice Address - Country:US
Practice Address - Phone:973-575-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00797100363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant