Provider Demographics
NPI:1215403969
Name:PEPOSE, DAVID (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:PEPOSE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:DAVID
Other - Middle Name:
Other - Last Name:PEPOSE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:619 W COUNTY LINE RD STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1215
Mailing Address - Country:US
Mailing Address - Phone:848-525-4201
Mailing Address - Fax:
Practice Address - Street 1:619 W COUNTY LINE RD STE 1
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1215
Practice Address - Country:US
Practice Address - Phone:732-730-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00499700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant