Provider Demographics
NPI:1306064357
Name:CICERALE, TANYA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TANYA
Middle Name:
Last Name:CICERALE
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 1:379 CAMPUS DR FL 4
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1161
Mailing Address - Country:US
Mailing Address - Phone:732-937-8939
Mailing Address - Fax:732-418-8372
Practice Address - Street 1:355 GRAND STREET
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07302
Practice Address - Country:US
Practice Address - Phone:201-915-2467
Practice Address - Fax:732-923-2272
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00144300363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical