Provider Demographics
NPI:1093200370
Name:MENNONNA, ALFREDO (PA-C)
Entity type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:MENNONNA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 EAST HANOVER AVE.
Mailing Address - Street 2:
Mailing Address - City:CEDAR KNOLLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07927
Mailing Address - Country:US
Mailing Address - Phone:973-605-8056
Mailing Address - Fax:973-605-8045
Practice Address - Street 1:100 MADISON AVE.
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960
Practice Address - Country:US
Practice Address - Phone:973-971-5488
Practice Address - Fax:973-290-7175
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00144800363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant