Provider Demographics
NPI:1942567524
Name:JOHN, STANLEY (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:JOHN
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 1:324 W CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-1903
Mailing Address - Country:US
Mailing Address - Phone:917-287-4154
Mailing Address - Fax:
Practice Address - Street 1:324 W CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-1903
Practice Address - Country:US
Practice Address - Phone:917-287-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2016-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00395900363A00000X
NY015558363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant