Provider Demographics
NPI:1043983695
Name:GUPTA, SIMRAN (PA-C)
Entity Type:Individual
Prefix:
First Name:SIMRAN
Middle Name:
Last Name:GUPTA
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 1:4 HENRY MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08620-9673
Mailing Address - Country:US
Mailing Address - Phone:609-433-7098
Mailing Address - Fax:
Practice Address - Street 1:1 ETHEL RD STE 106D
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08817-2838
Practice Address - Country:US
Practice Address - Phone:732-650-0040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00633900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant