Provider Demographics
NPI:1043554512
Name:PEDATELLA, IWONA (PA-C)
Entity Type:Individual
Prefix:
First Name:IWONA
Middle Name:
Last Name:PEDATELLA
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 1:4000 RIVERDALE RD
Mailing Address - Street 2:402
Mailing Address - City:RIVERDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07457-1729
Mailing Address - Country:US
Mailing Address - Phone:973-896-1344
Mailing Address - Fax:
Practice Address - Street 1:221 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:MONTVALE
Practice Address - State:NJ
Practice Address - Zip Code:07645-1729
Practice Address - Country:US
Practice Address - Phone:201-307-0075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00290300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical