Provider Demographics
NPI:1922335371
Name:SHORE NURSE PRACTITIONER GROUP LLC
Entity Type:Organization
Organization Name:SHORE NURSE PRACTITIONER GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MUSTAK
Authorized Official - Middle Name:
Authorized Official - Last Name:RAHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPC,CPC-H
Authorized Official - Phone:848-466-6011
Mailing Address - Street 1:71 ANNAPOLIS ST
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-3175
Mailing Address - Country:US
Mailing Address - Phone:848-466-6011
Mailing Address - Fax:732-493-8475
Practice Address - Street 1:71 ANNAPOLIS ST
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07712-3175
Practice Address - Country:US
Practice Address - Phone:848-466-6011
Practice Address - Fax:732-493-8475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00037000363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty