Provider Demographics
NPI:1740727791
Name:QUIDANGEN, BENJAMIN
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:QUIDANGEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LEWIS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-6017
Mailing Address - Country:US
Mailing Address - Phone:201-957-4114
Mailing Address - Fax:
Practice Address - Street 1:12 LEWIS ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-6017
Practice Address - Country:US
Practice Address - Phone:201-957-4114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340063363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily