Provider Demographics
NPI:1750590451
Name:FELICIANO, HERNAN (PA)
Entity type:Individual
Prefix:MR
First Name:HERNAN
Middle Name:
Last Name:FELICIANO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 TRALEE RD
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730-1148
Mailing Address - Country:US
Mailing Address - Phone:732-888-3671
Mailing Address - Fax:
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-6680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00102600363AS0400X
NY005884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant