Provider Demographics
NPI:1023562568
Name:AMAZAN, ROSE MAYARD
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:MAYARD
Last Name:AMAZAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4539 ROUTE 9 N
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07731-3380
Mailing Address - Country:US
Mailing Address - Phone:732-987-8200
Mailing Address - Fax:732-987-5964
Practice Address - Street 1:4539 ROUTE 9 N
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:NJ
Practice Address - Zip Code:07731-3380
Practice Address - Country:US
Practice Address - Phone:732-987-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-13
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN583583163W00000X
PAF1216021363LF0000X
NJ27NJ00716300363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1023562568Medicaid