Provider Demographics
NPI:1003954074
Name:CULLEN, ALISA G (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:G
Last Name:CULLEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 NORTHFIELD AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1144
Mailing Address - Country:US
Mailing Address - Phone:973-736-0041
Mailing Address - Fax:973-736-0044
Practice Address - Street 1:745 NORTHFIELD AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1144
Practice Address - Country:US
Practice Address - Phone:973-736-0041
Practice Address - Fax:973-736-0044
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00091800363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP81367Medicare UPIN