Provider Demographics
NPI:1386668457
Name:RUIZ, PETER-JOHN (RPA-C)
Entity Type:Individual
Prefix:
First Name:PETER-JOHN
Middle Name:
Last Name:RUIZ
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 EXPRESS DR N
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5301
Mailing Address - Country:US
Mailing Address - Phone:631-439-0600
Mailing Address - Fax:631-439-0699
Practice Address - Street 1:3001 EXPRESS DR N
Practice Address - Street 2:SUITE 102
Practice Address - City:ISLANDIA
Practice Address - State:NY
Practice Address - Zip Code:11749-5301
Practice Address - Country:US
Practice Address - Phone:631-439-0600
Practice Address - Fax:631-439-0699
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009825-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMR1228560OtherDEA NUMBER