Provider Demographics
NPI:1972102770
Name:KODRA, VANESA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:VANESA
Middle Name:
Last Name:KODRA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 ANDERSON AVE APT 2J
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-2707
Mailing Address - Country:US
Mailing Address - Phone:201-247-5226
Mailing Address - Fax:
Practice Address - Street 1:1590 ANDERSON AVE APT 2J
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-2707
Practice Address - Country:US
Practice Address - Phone:201-247-5226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant