Provider Demographics
NPI:1144536152
Name:DERAVILLE, JOSEPH N SR (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:N
Last Name:DERAVILLE
Suffix:SR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:557 NEW DOVER RD
Mailing Address - Street 2:
Mailing Address - City:ISELIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08830-1127
Mailing Address - Country:US
Mailing Address - Phone:732-388-4128
Mailing Address - Fax:
Practice Address - Street 1:557 NEW DOVER RD
Practice Address - Street 2:
Practice Address - City:ISELIN
Practice Address - State:NJ
Practice Address - Zip Code:08830-1127
Practice Address - Country:US
Practice Address - Phone:732-388-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00142700363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical