Provider Demographics
NPI:1760725998
Name:SPINA, ALICE JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:JEAN
Last Name:SPINA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 DEVON RD
Mailing Address - Street 2:
Mailing Address - City:LONG VALLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07853-3233
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:254 MOUNTAIN AVE
Practice Address - Street 2:BUILDING B SUITE 102
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-2407
Practice Address - Country:US
Practice Address - Phone:908-979-1621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-06
Last Update Date:2013-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00027800363A00000X
NY004812-1363A00000X
PAMA-002350-L363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical