Provider Demographics
NPI:1437856648
Name:PRODIGY AESTHETICS
Entity Type:Organization
Organization Name:PRODIGY AESTHETICS
Other - Org Name:PRODIGY AESTHETICS AND PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:CEDENO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:973-221-5527
Mailing Address - Street 1:680 BROADWAY STE 205
Mailing Address - Street 2:
Mailing Address - City:PATERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07514-1527
Mailing Address - Country:US
Mailing Address - Phone:973-790-0123
Mailing Address - Fax:
Practice Address - Street 1:680 BROADWAY STE 205
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07514-1527
Practice Address - Country:US
Practice Address - Phone:973-790-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-08
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty