Provider Demographics
NPI:1912088972
Name:SIDWA, VICKIE SUZANNE (APN, C)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:SUZANNE
Last Name:SIDWA
Suffix:
Gender:F
Credentials:APN, C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1043 MONTAUK DR
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-2004
Mailing Address - Country:US
Mailing Address - Phone:609-339-5667
Mailing Address - Fax:
Practice Address - Street 1:1043 MONTAUK DR
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2004
Practice Address - Country:US
Practice Address - Phone:609-339-5667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN10119300363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJS83820Medicare UPIN