Provider Demographics
NPI:1225698202
Name:ANIS, SIDRA
Entity Type:Individual
Prefix:
First Name:SIDRA
Middle Name:
Last Name:ANIS
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 1:1 DIAMOND HILL RD
Mailing Address - Street 2:
Mailing Address - City:BERKELEY HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07922-2104
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:904 BAYONNE CROSSING WAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-5307
Practice Address - Country:US
Practice Address - Phone:551-497-5675
Practice Address - Fax:551-497-5676
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NJ25MP00645300363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant