Provider Demographics
NPI:1518324920
Name:DEGAZON, MARVA
Entity Type:Individual
Prefix:
First Name:MARVA
Middle Name:
Last Name:DEGAZON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 WOODHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5166
Mailing Address - Country:US
Mailing Address - Phone:973-907-2955
Mailing Address - Fax:
Practice Address - Street 1:91 WOODHAVEN DR
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-5166
Practice Address - Country:US
Practice Address - Phone:973-907-2955
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198310-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4623196240Medicare NSC