Provider Demographics
NPI:1699924761
Name:CAUSSIMON, MARTINE P (PA)
Entity type:Individual
Prefix:
First Name:MARTINE
Middle Name:P
Last Name:CAUSSIMON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 S MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4561
Mailing Address - Country:US
Mailing Address - Phone:201-445-2830
Mailing Address - Fax:
Practice Address - Street 1:85 S MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4561
Practice Address - Country:US
Practice Address - Phone:201-445-2830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP0020110363A00000X
NJ25MP00201100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ135141WX5Medicare PIN