Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | 25MA04460500 | NJ |
NPI | 1063472694 |
---|---|
Provider Name | Charles P Fernicola |
First Address | Manahawkin, NJ 08050-2471 |
Second Address | Manahawkin, NJ 08050-2471 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2006 |
Last Update Date | 14/03/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3131602 | (05) | NJ |
C59866 | (02) | NJ |