Provider Demographics
NPI:1073207387
Name:RUIZ, KRISTIN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARIE
Last Name:RUIZ
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 1:2319 MILL RD
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-1406
Mailing Address - Country:US
Mailing Address - Phone:631-848-6964
Mailing Address - Fax:
Practice Address - Street 1:1010 ROUTE 112 STE 300
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3386
Practice Address - Country:US
Practice Address - Phone:631-364-9119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029974363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical