Provider Demographics
NPI:1457079139
Name:GHANAIM, ALISA MARGARET (PA-C)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:MARGARET
Last Name:GHANAIM
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 1:2150 PERRINE RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08836-2305
Mailing Address - Country:US
Mailing Address - Phone:732-397-8082
Mailing Address - Fax:
Practice Address - Street 1:1005 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812-2698
Practice Address - Country:US
Practice Address - Phone:732-968-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00727000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant