Provider Demographics
NPI:1427222710
Name:NICOLETTA-GAJANO, TARA ANIELA (PA)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:ANIELA
Last Name:NICOLETTA-GAJANO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:TARA
Other - Middle Name:ANIELA
Other - Last Name:NICOLETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3600 ROUTE 66 FL 3
Mailing Address - Street 2:
Mailing Address - City:NEPTUNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07753-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1610 ROUTE 88 STE 203
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-3018
Practice Address - Country:US
Practice Address - Phone:732-840-3339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-17
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP000542363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical