Provider Demographics
NPI:1225550353
Name:CORDIELLO, KRISTEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:CORDIELLO
Suffix:
Gender:F
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 1:17 AZEE DR
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-2658
Mailing Address - Country:US
Mailing Address - Phone:732-895-0654
Mailing Address - Fax:
Practice Address - Street 1:1610 ROUTE 88 STE 203
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3018
Practice Address - Country:US
Practice Address - Phone:732-840-3339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2017-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00440500363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical