Provider Demographics
NPI:1356014518
Name:FOBBEN, MARIE ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:ROSE
Last Name:FOBBEN
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 1:128 COLUMBIA TPKE STE 200
Mailing Address - Street 2:
Mailing Address - City:FLORHAM PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07932-2283
Mailing Address - Country:US
Mailing Address - Phone:973-736-9535
Mailing Address - Fax:
Practice Address - Street 1:128 COLUMBIA TPKE STE 200
Practice Address - Street 2:
Practice Address - City:FLORHAM PARK
Practice Address - State:NJ
Practice Address - Zip Code:07932-2283
Practice Address - Country:US
Practice Address - Phone:973-736-9535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-26
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00632500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant