Provider Demographics
NPI:1588910772
Name:SCAVONE, KERIANN MICHELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KERIANN
Middle Name:MICHELLE
Last Name:SCAVONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KERIANN
Other - Middle Name:MICHELLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:195 LITTLE ALBANY ST
Mailing Address - Street 2:
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1914
Mailing Address - Country:US
Mailing Address - Phone:732-235-4023
Mailing Address - Fax:732-235-3299
Practice Address - Street 1:195 LITTLE ALBANY ST
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1914
Practice Address - Country:US
Practice Address - Phone:732-235-4023
Practice Address - Fax:732-235-3299
Is Sole Proprietor?:No
Enumeration Date:2012-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00373300363A00000X
NY015742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0157421OtherPHYSICIAN ASSISTANT LICENSE
A00379400OtherNJ CDS LICENSE
NJ25MP00373300OtherPHYSICIAN ASSISTANT LICENSE
NJ25MP00373300OtherPHYSICIAN ASSISTANT LICENSE