Provider Demographics
NPI:1972076636
Name:DESAI, SAMONE
Entity Type:Individual
Prefix:
First Name:SAMONE
Middle Name:
Last Name:DESAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6603 HANA RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2546
Mailing Address - Country:US
Mailing Address - Phone:848-219-6415
Mailing Address - Fax:
Practice Address - Street 1:9225 KENNEDY BLVD STE B
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5361
Practice Address - Country:US
Practice Address - Phone:201-453-2800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-05
Last Update Date:2019-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00497300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant