Provider Demographics
NPI:1427113265
Name:HUR, SALLY M (PAC)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:HUR
Suffix:
Gender:
Credentials:PAC
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:M
Other - Last Name:HUR SHAFFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:973-290-7495
Practice Address - Street 1:100 MADISON AVE # GAGNONC
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-6136
Practice Address - Country:US
Practice Address - Phone:973-971-7300
Practice Address - Fax:973-984-7019
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP00105200363AS0400X
NJ25MP001052363AS0400X
NJ25MP00105200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
088624B9MMedicare PIN
088624Medicare PIN
NJ088624Medicare ID - Type Unspecified
NJQ37808Medicare UPIN