Provider Demographics
NPI:1568613925
Name:NACIM, STEPHANIE J (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:J
Last Name:NACIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:J
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 859
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-0859
Mailing Address - Country:US
Mailing Address - Phone:800-345-0064
Mailing Address - Fax:
Practice Address - Street 1:1544 KUSER RD STE C9
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-3830
Practice Address - Country:US
Practice Address - Phone:734-329-5419
Practice Address - Fax:855-716-4494
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00204100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ135609Medicare PIN