Provider Demographics
NPI:1528002565
Name:BEVILACQUA, BABETTE (PA)
Entity Type:Individual
Prefix:MRS
First Name:BABETTE
Middle Name:
Last Name:BEVILACQUA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1326
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07962-1326
Mailing Address - Country:US
Mailing Address - Phone:973-538-2334
Mailing Address - Fax:973-538-1297
Practice Address - Street 1:130 E 77TH ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1851
Practice Address - Country:US
Practice Address - Phone:516-622-6000
Practice Address - Fax:516-608-6819
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005309-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWNW221Medicare PIN
NYA400011113Medicare PIN
P79122Medicare UPIN
5F6231Medicare ID - Type Unspecified
NY5F6231Medicare PIN