Provider Demographics
NPI:1558369363
Name:ERVILUS, PATRICK A (NPC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:A
Last Name:ERVILUS
Suffix:
Gender:M
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 W COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:WESTAMPTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08060-4741
Mailing Address - Country:US
Mailing Address - Phone:609-702-5808
Mailing Address - Fax:609-702-5809
Practice Address - Street 1:2809 RIVER RD
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08105-4426
Practice Address - Country:US
Practice Address - Phone:856-966-8088
Practice Address - Fax:856-966-8089
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-14
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10322000363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7523203Medicaid
NJ005731Medicare ID - Type Unspecified
NJ7523203Medicaid