Provider Demographics
NPI:1073063012
Name:DERITIS, MIA
Entity Type:Individual
Prefix:MISS
First Name:MIA
Middle Name:
Last Name:DERITIS
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 1:1 CAPITAL WAY
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-2520
Mailing Address - Country:US
Mailing Address - Phone:800-637-2374
Mailing Address - Fax:
Practice Address - Street 1:1 CAPITAL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2520
Practice Address - Country:US
Practice Address - Phone:800-637-2374
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-13
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00518400363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical