Provider Demographics
NPI:1629169768
Name:TATEVOSYAN, LUSINE (PA)
Entity Type:Individual
Prefix:MS
First Name:LUSINE
Middle Name:
Last Name:TATEVOSYAN
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 29008
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101
Mailing Address - Country:US
Mailing Address - Phone:201-845-9300
Mailing Address - Fax:201-845-9301
Practice Address - Street 1:10 FOREST AVENUE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652
Practice Address - Country:US
Practice Address - Phone:201-291-4040
Practice Address - Fax:201-291-0404
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00165700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant