Provider Demographics
NPI:1295374346
Name:IPANAQUE, ROCIO LIZET (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:ROCIO
Middle Name:LIZET
Last Name:IPANAQUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:214 ROUTE 36
Mailing Address - Street 2:
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1305
Mailing Address - Country:US
Mailing Address - Phone:732-222-8000
Mailing Address - Fax:732-963-2246
Practice Address - Street 1:214 ROUTE 36
Practice Address - Street 2:
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1305
Practice Address - Country:US
Practice Address - Phone:732-222-8000
Practice Address - Fax:732-963-2246
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-06
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00553500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant