Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 006765 | NY |
NPI | 1114678646 |
---|---|
Provider Name | Mr. Michael Pasquale Derenzo |
First Address | Blackwood, NJ 08012-5103 |
Second Address | Blackwood, NJ 08012-5103 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/01/2022 |
Last Update Date | 17/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
006765 | LICENSED OPTICIAN (01) | NY |