Provider Demographics
NPI:1447695044
Name:20 CLAIR STREET
Entity type:Organization
Organization Name:20 CLAIR STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:DARSHANABAHEN
Authorized Official - Middle Name:JAYESHKUMAR
Authorized Official - Last Name:MISTRY
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:973-473-3163
Mailing Address - Street 1:20 CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-2618
Mailing Address - Country:US
Mailing Address - Phone:973-473-3163
Mailing Address - Fax:
Practice Address - Street 1:20 CLAIR ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-2618
Practice Address - Country:US
Practice Address - Phone:973-473-3163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00431900364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult HealthGroup - Single Specialty