Provider Demographics
NPI:1811408313
Name:BOOTH, MICHAEL TYLER (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:TYLER
Last Name:BOOTH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39 CEDAR GROVE PKWY
Mailing Address - Street 2:
Mailing Address - City:CEDAR GROVE
Mailing Address - State:NJ
Mailing Address - Zip Code:07009-1405
Mailing Address - Country:US
Mailing Address - Phone:973-738-0627
Mailing Address - Fax:
Practice Address - Street 1:784 FRANKLIN AVE STE 250
Practice Address - Street 2:
Practice Address - City:FRANKLIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07417-1306
Practice Address - Country:US
Practice Address - Phone:844-777-0910
Practice Address - Fax:201-560-0712
Is Sole Proprietor?:No
Enumeration Date:2017-10-24
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00452000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant