Provider Demographics
NPI:1801199484
Name:MENASHY, NISSIM (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:NISSIM
Middle Name:
Last Name:MENASHY
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 IROQUOIS PL
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1134
Mailing Address - Country:US
Mailing Address - Phone:732-552-4488
Mailing Address - Fax:
Practice Address - Street 1:27 S COOKS BRIDGE RD
Practice Address - Street 2:SUITE 2-2
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-2524
Practice Address - Country:US
Practice Address - Phone:732-370-4222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-21
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00251000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ229641YBRYMedicare PIN