Provider Demographics
NPI:1962425769
Name:GOZDZIALSKI, STEPHANIE K (PA-C)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:K
Last Name:GOZDZIALSKI
Suffix:
Gender:F
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 1:499 BECKETT RD
Mailing Address - Street 2:SUITE 201 B
Mailing Address - City:LOGAN TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-1766
Mailing Address - Country:US
Mailing Address - Phone:856-467-6400
Mailing Address - Fax:
Practice Address - Street 1:499 BECKETT RD
Practice Address - Street 2:SUITE 201 B
Practice Address - City:LOGAN TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08085-1766
Practice Address - Country:US
Practice Address - Phone:856-467-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00198100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q70594Medicare UPIN