Provider Demographics
NPI:1811278906
Name:TAVAREZ, CRISTINA R (MS, PA-C)
Entity type:Individual
Prefix:MS
First Name:CRISTINA
Middle Name:R
Last Name:TAVAREZ
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:465 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2907
Mailing Address - Country:US
Mailing Address - Phone:973-483-3640
Mailing Address - Fax:973-483-4895
Practice Address - Street 1:465 MOUNT PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104-2907
Practice Address - Country:US
Practice Address - Phone:973-483-3640
Practice Address - Fax:973-483-4895
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00265700363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical