Provider Demographics
NPI:1386673655
Name:TEA, RICHARD V (PA-C)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:V
Last Name:TEA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:VICHET
Other - Middle Name:
Other - Last Name:TEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2 CONTINENTAL CIR
Mailing Address - Street 2:
Mailing Address - City:TOTOWA
Mailing Address - State:NJ
Mailing Address - Zip Code:07512-2191
Mailing Address - Country:US
Mailing Address - Phone:201-780-7582
Mailing Address - Fax:
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:CT SURGERY DEPT
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055
Practice Address - Country:US
Practice Address - Phone:973-365-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2011-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00056200363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical