Provider Demographics
NPI:1447621909
Name:ENOCK, MIRIAM
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:ENOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S ORANGE AVE
Mailing Address - Street 2:SUITE A-1020
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2785
Mailing Address - Country:US
Mailing Address - Phone:973-972-3066
Mailing Address - Fax:
Practice Address - Street 1:205 S ORANGE AVE
Practice Address - Street 2:SUITE A-1020
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2785
Practice Address - Country:US
Practice Address - Phone:973-972-3066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00368500363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical