Basic Information
| Provider Information | |||||||||
| NPI: | 1497934459 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | RAEKEISHA | ||||||||
| MiddleName: | |||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082734300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 DIAMOND HILL RD | ||||||||
| Address2: | |||||||||
| City: | BERKELEY HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079222104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082734300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2007 | ||||||||
| LastUpdateDate: | 01/13/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00114200 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 25MP00114200 | 01 | NJ | LICENSE | OTHER |