Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | MB66800 | NJ |
NPI | 1003836917 |
---|---|
Provider Name | Elaine Bacci |
First Address | Sea Girt, NJ 08750-1011 |
Second Address | Red Bank, NJ 07701 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 09/04/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7966300 | (05) | NJ |
F57774 | (02) |