Provider Demographics
NPI:1760698617
Name:VITERBO, ANTONELLA F (MS,PA-C)
Entity Type:Individual
Prefix:
First Name:ANTONELLA
Middle Name:F
Last Name:VITERBO
Suffix:
Gender:F
Credentials:MS,PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 MAXIM COURT
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527
Mailing Address - Country:US
Mailing Address - Phone:215-584-6731
Mailing Address - Fax:
Practice Address - Street 1:135 KINNELON RD RM 103
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2333
Practice Address - Country:US
Practice Address - Phone:973-838-1771
Practice Address - Fax:973-492-2858
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00178900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223777917OtherCOMMERCIAL INSURANCES