Provider Demographics
NPI:1215457940
Name:VASCONCELLOS, JULIANNE RENEE (PA-C)
Entity type:Individual
Prefix:MS
First Name:JULIANNE
Middle Name:RENEE
Last Name:VASCONCELLOS
Suffix:
Gender:F
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 1:298 6TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07302-6913
Mailing Address - Country:US
Mailing Address - Phone:466-990-8800
Mailing Address - Fax:
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:646-990-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 363AM0700X
NJ25MP00439500363A00000X
NY020944-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY020944-1Medicaid
NJ25MP00439500OtherNEW JERSEY PHYSICIAN ASSISTANT LICENSE
NJ25MP00439500OtherNEW JERSEY PHYSICIAN ASSISTANT LICENSE