Provider Demographics
NPI:1174040539
Name:AVICHAL, KEVIN SHAILESH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:SHAILESH
Last Name:AVICHAL
Suffix:
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 1:1244 PLANE ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-3820
Mailing Address - Country:US
Mailing Address - Phone:908-265-7873
Mailing Address - Fax:
Practice Address - Street 1:526 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3734
Practice Address - Country:US
Practice Address - Phone:201-437-9700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-26
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021217363A00000X
NJ25MP00445700363A00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant