Basic Information
| Provider Information | |||||||||
| NPI: | 1003147976 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VARGHESE | ||||||||
| FirstName: | SANJU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APN-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND STREET | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015290033 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 137 GREENBRIAR ST | ||||||||
| Address2: | #2 | ||||||||
| City: | BERGENFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076214226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2012445912 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2010 | ||||||||
| LastUpdateDate: | 10/17/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 26NJ00269800 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.