Provider Demographics
NPI:1417140369
Name:HART, GEORGIANA
Entity Type:Individual
Prefix:
First Name:GEORGIANA
Middle Name:
Last Name:HART
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 1:590 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07107-2522
Mailing Address - Country:US
Mailing Address - Phone:973-596-5101
Mailing Address - Fax:973-482-1978
Practice Address - Street 1:58 FREEMAN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-4005
Practice Address - Country:US
Practice Address - Phone:973-596-4190
Practice Address - Fax:973-639-6583
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-23
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO06625800364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ000070000OtherAPN LICENSE
NJ196925YPPMedicaid
NJ26NJ000070000OtherAPN LICENSE