Provider Demographics
NPI:1689182867
Name:BALWALLI-UDYAWER, SHRUTI (APN)
Entity Type:Individual
Prefix:
First Name:SHRUTI
Middle Name:
Last Name:BALWALLI-UDYAWER
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3967
Mailing Address - Country:US
Mailing Address - Phone:732-452-9700
Mailing Address - Fax:732-452-9720
Practice Address - Street 1:149 MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08882-1232
Practice Address - Country:US
Practice Address - Phone:732-238-6440
Practice Address - Fax:732-651-1232
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-22
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00769400363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ00769400OtherLICENSE