Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2081S0010X | Sports Medicine | 40QB00391200 | NJ |
Y | 213ES0000X | Sports Medicine | 40QB00391200 | NJ |
NPI | 1437819851 |
---|---|
Provider Name | Ms. Shanice Alicia Bancroft |
First Address | Newark, NJ 07112-3073 |
Second Address | Newark, NJ 07112-3073 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/12/2021 |
Last Update Date | 27/12/2021 |