Provider Demographics
NPI:1255332474
Name:DEVROYE, MARILYN (PA)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:
Last Name:DEVROYE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RUSSELL PL
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:NJ
Mailing Address - Zip Code:07901-3814
Mailing Address - Country:US
Mailing Address - Phone:908-522-1072
Mailing Address - Fax:
Practice Address - Street 1:1 DIAMOND HILL RD
Practice Address - Street 2:
Practice Address - City:BERKELEY HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07922
Practice Address - Country:US
Practice Address - Phone:908-273-4300
Practice Address - Fax:908-673-7336
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005217-1363A00000X
NJ25MP00017800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
085518NM3Medicare ID - Type Unspecified
Q16669Medicare UPIN