Provider Demographics
NPI:1497781140
Name:VALLARTA, JOHN-ERIC (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN-ERIC
Middle Name:
Last Name:VALLARTA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 PINE TREE DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5426
Mailing Address - Country:US
Mailing Address - Phone:732-236-1772
Mailing Address - Fax:
Practice Address - Street 1:1 BAY AVENUE
Practice Address - Street 2:MOUNTAINSIDE MEDICAL CENTER
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042
Practice Address - Country:US
Practice Address - Phone:973-429-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26N011136700163W00000X
KY5116A367500000X
NJ26NJ00341600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100005840Medicaid
KY000000521892OtherBCBS
KY7100005840Medicaid
KYP00403285Medicare PIN
KY0935399Medicare PIN
NJ054129Medicare PIN