Individual
TIMOTHY MANCUSO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
5 LARSON CT, NORTH BRUNSWICK, NJ 08902-9636
(732) 512-8585
Mailing address
5 LARSON CT, NORTH BRUNSWICK, NJ 08902-9636
(908) 635-8354
Taxonomy
Speciality
Code
Description
License number
State
2255A2300X
Athletic Trainer
Primary
25MT00187000
NJ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
RJU3HZN96119450
BLUECROSS BLUESHIELD
NJ
Enumeration date
09/13/2019
Last updated
09/13/2019
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