Provider Demographics
NPI:1114159506
Name:ETWARU, VASHTI
Entity Type:Individual
Prefix:MRS
First Name:VASHTI
Middle Name:
Last Name:ETWARU
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 1:22 CROWN VIEW CT
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3569
Mailing Address - Country:US
Mailing Address - Phone:516-343-5339
Mailing Address - Fax:
Practice Address - Street 1:649 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1526
Practice Address - Country:US
Practice Address - Phone:973-795-7955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013232363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical