Provider Demographics
NPI:1326474628
Name:KRIVAK, ASHLEY TAVARES
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:TAVARES
Last Name:KRIVAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 9TH ST APT 214
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-2185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 MADISON AVE
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-971-6634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-18
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016982363A00000X
NJ25MP00321600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant