Provider Demographics
NPI:1487333506
Name:SERRA, DANIEL MATTHEW (APN)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MATTHEW
Last Name:SERRA
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 E RIDGEWOOD AVE APT 8
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3331
Mailing Address - Country:US
Mailing Address - Phone:201-377-8218
Mailing Address - Fax:
Practice Address - Street 1:223 N VAN DIEN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-2736
Practice Address - Country:US
Practice Address - Phone:201-447-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01477800363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty