Provider Demographics
NPI:1598295883
Name:PRINCIVIL, GEORGES M (PA)
Entity Type:Individual
Prefix:
First Name:GEORGES
Middle Name:M
Last Name:PRINCIVIL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1087 E JERSEY ST APT C2
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2550
Mailing Address - Country:US
Mailing Address - Phone:908-937-0535
Mailing Address - Fax:
Practice Address - Street 1:812 FOREST AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2446
Practice Address - Country:US
Practice Address - Phone:718-571-9196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00434900363A00000X, 363AS0400X
NY023465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty