Provider Demographics
NPI:1326312430
Name:BOOCKOFF, BRIAN W (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:W
Last Name:BOOCKOFF
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-796-9397
Practice Address - Street 1:414 TATUM ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3499
Practice Address - Country:US
Practice Address - Phone:856-848-3880
Practice Address - Fax:856-848-4895
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00280500363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
336082AQVMedicare PIN