Provider Demographics
NPI:1003326133
Name:MATARAGAS, KENNETH RYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:RYAN
Last Name:MATARAGAS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NY-112
Mailing Address - Street 2:BUILDING 6 SUITE C
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776
Mailing Address - Country:US
Mailing Address - Phone:631-732-9090
Mailing Address - Fax:
Practice Address - Street 1:1500 NY-112 BUILDING 6
Practice Address - Street 2:SUITE C
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776
Practice Address - Country:US
Practice Address - Phone:631-732-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2024-01-17
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant