Provider Demographics
NPI:1255849212
Name:COLLETTI, TATIANA (PA)
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:COLLETTI
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 1:75 VERONICA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5002
Mailing Address - Country:US
Mailing Address - Phone:732-247-7444
Mailing Address - Fax:
Practice Address - Street 1:75 VERONICA AVE STE 101
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5002
Practice Address - Country:US
Practice Address - Phone:732-247-7444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-11
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00460300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant