Provider Demographics
NPI:1336163716
Name:FEDORUK, SUSAN (APN)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:FEDORUK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 JACK MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7732
Mailing Address - Country:US
Mailing Address - Phone:732-836-4504
Mailing Address - Fax:732-836-4532
Practice Address - Street 1:425 JACK MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7732
Practice Address - Country:US
Practice Address - Phone:732-836-4504
Practice Address - Fax:732-836-4532
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO07839100363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner