Provider Demographics
NPI:1639640790
Name:TAGUIAM, DIRKSEN J (MSN, APN-C)
Entity Type:Individual
Prefix:
First Name:DIRKSEN
Middle Name:J
Last Name:TAGUIAM
Suffix:
Gender:M
Credentials:MSN, APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 JACK MARTIN BLVD STE D-1
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7771
Mailing Address - Country:US
Mailing Address - Phone:732-458-5854
Mailing Address - Fax:732-458-8012
Practice Address - Street 1:210 JACK MARTIN BLVD STE D-1
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7771
Practice Address - Country:US
Practice Address - Phone:732-458-5854
Practice Address - Fax:732-458-8012
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00885000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner