Provider Demographics
NPI:1053759738
Name:DE LA CRUZ, GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:DE LA CRUZ
Suffix:
Gender:F
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 1:1345 RXR PLZ
Mailing Address - Street 2:
Mailing Address - City:UNIONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11556-1301
Mailing Address - Country:US
Mailing Address - Phone:516-453-0435
Mailing Address - Fax:
Practice Address - Street 1:1255 RARITAN RD STE F4B
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1200
Practice Address - Country:US
Practice Address - Phone:848-206-0072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016426363A00000X
NJ25MP00304700363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant