Provider Demographics
NPI:1417387572
Name:BLACK, ALIZA
Entity Type:Individual
Prefix:
First Name:ALIZA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALIZA
Other - Middle Name:
Other - Last Name:BERKOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:78 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-3616
Mailing Address - Country:US
Mailing Address - Phone:917-776-8725
Mailing Address - Fax:
Practice Address - Street 1:78 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-3616
Practice Address - Country:US
Practice Address - Phone:917-776-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant