Provider Demographics
NPI:1659986974
Name:BANSRUPAN, JOSIAN C
Entity Type:Individual
Prefix:
First Name:JOSIAN
Middle Name:C
Last Name:BANSRUPAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 NEWARK PL
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-1916
Mailing Address - Country:US
Mailing Address - Phone:201-241-8250
Mailing Address - Fax:
Practice Address - Street 1:50 NEWARK PL
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-1916
Practice Address - Country:US
Practice Address - Phone:202-241-8250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ18KT00725400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist