Basic Information
| Provider Information | |||||||||
| NPI: | 1336595800 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PORTANOVA | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 45 EUCLID ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080964631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566284504 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 45 EUCLID ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080964631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566284504 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2016 | ||||||||
| LastUpdateDate: | 07/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 26NJ00628000 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | SP015756 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.