Provider Demographics
NPI:1568189322
Name:MASULLO, SCOTT CARMINE SR (NP)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:CARMINE
Last Name:MASULLO
Suffix:SR
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 WATCHUNG PL
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2031
Mailing Address - Country:US
Mailing Address - Phone:973-943-7333
Mailing Address - Fax:
Practice Address - Street 1:382 W PASSAIC AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-5554
Practice Address - Country:US
Practice Address - Phone:973-338-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01370400363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily