Provider Demographics
NPI:1073273769
Name:PERUTTI, BERNARD FAVARATO (AGPCNP)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:FAVARATO
Last Name:PERUTTI
Suffix:
Gender:M
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-2225
Mailing Address - Country:US
Mailing Address - Phone:973-392-1419
Mailing Address - Fax:
Practice Address - Street 1:90 W RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2270
Practice Address - Country:US
Practice Address - Phone:201-652-1950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2021083443363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner