Provider Demographics
NPI:1043089303
Name:YDO, JUSTIN (AGNP-C)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:
Last Name:YDO
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 NORTHFIELD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-1140
Mailing Address - Country:US
Mailing Address - Phone:908-315-9055
Mailing Address - Fax:
Practice Address - Street 1:776 NORTHFIELD AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-1140
Practice Address - Country:US
Practice Address - Phone:973-324-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-28
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14981300363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner