Provider Demographics
NPI:1093957813
Name:MANSUKHANI, JANINE MARY
Entity Type:Individual
Prefix:MISS
First Name:JANINE
Middle Name:MARY
Last Name:MANSUKHANI
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:JANINE
Other - Middle Name:MARY
Other - Last Name:GEHSHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:40 CONCORD LN
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1343
Mailing Address - Country:US
Mailing Address - Phone:646-823-4212
Mailing Address - Fax:
Practice Address - Street 1:350 ENGLE ST FL 5
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-1808
Practice Address - Country:US
Practice Address - Phone:201-894-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-25
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013151363A00000X
NJ25MP00653600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0893552Medicaid