Provider Demographics
NPI:1407657141
Name:QUISPE, CEIDA (PA-C)
Entity type:Individual
Prefix:
First Name:CEIDA
Middle Name:
Last Name:QUISPE
Suffix:
Gender:
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 1:625 LEGION CT
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1109
Mailing Address - Country:US
Mailing Address - Phone:908-230-5176
Mailing Address - Fax:
Practice Address - Street 1:26 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-1302
Practice Address - Country:US
Practice Address - Phone:973-672-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00921600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant