Provider Demographics
NPI:1306223045
Name:AVANESYAN, ANNA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:M
Last Name:AVANESYAN
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 1:17-15 MAPLE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-1552
Mailing Address - Country:US
Mailing Address - Phone:201-794-8055
Mailing Address - Fax:201-794-8086
Practice Address - Street 1:17-15 MAPLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-1552
Practice Address - Country:US
Practice Address - Phone:201-794-8055
Practice Address - Fax:201-794-8086
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00336500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant