Provider Demographics
NPI:1043790165
Name:DIMATULAC, MISAEL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:MISAEL
Middle Name:
Last Name:DIMATULAC
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 MAPLE DR
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1333
Mailing Address - Country:US
Mailing Address - Phone:646-525-9621
Mailing Address - Fax:
Practice Address - Street 1:43 MAPLE DR
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1333
Practice Address - Country:US
Practice Address - Phone:646-525-9621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily