Provider Demographics
NPI:1932602299
Name:SOLLY, MAIMOUNA (PA)
Entity Type:Individual
Prefix:
First Name:MAIMOUNA
Middle Name:
Last Name:SOLLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CRANBURY RD FL 2
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-4096
Mailing Address - Country:US
Mailing Address - Phone:732-390-7750
Mailing Address - Fax:732-390-7725
Practice Address - Street 1:3 PROGRESS ST STE 100
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1180
Practice Address - Country:US
Practice Address - Phone:908-757-9696
Practice Address - Fax:908-757-9721
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00519100363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0749460Medicaid
NJ14948929OtherCAQH ID