Provider Demographics
NPI:1467057935
Name:ESPOSITO, THERESA C (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:C
Last Name:ESPOSITO
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 1:56 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08031-2222
Mailing Address - Country:US
Mailing Address - Phone:201-290-1954
Mailing Address - Fax:
Practice Address - Street 1:136 N WASHINGTON AVE STE 203
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-1776
Practice Address - Country:US
Practice Address - Phone:201-374-1718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00589300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant