Provider Demographics
NPI:1225121064
Name:HUNTLEY, BRUCE W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:W
Last Name:HUNTLEY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:HIGH BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08829-1528
Mailing Address - Country:US
Mailing Address - Phone:908-638-5160
Mailing Address - Fax:
Practice Address - Street 1:600 N WOLFE ST
Practice Address - Street 2:MARBURG B-186
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0005
Practice Address - Country:US
Practice Address - Phone:410-283-0896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP000308363A00000X
MD0003460363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS52160Medicare UPIN
NJ004207Medicare ID - Type Unspecified