Provider Demographics
NPI:1497416119
Name:JEGANATHAN, RONALD KRISHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:KRISHAN
Last Name:JEGANATHAN
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 1:35 PILCHER ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6307
Mailing Address - Country:US
Mailing Address - Phone:646-709-2191
Mailing Address - Fax:
Practice Address - Street 1:274 MADISON AVE RM 1501
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-0701
Practice Address - Country:US
Practice Address - Phone:646-709-2191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2023-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
390200000X
NY028922363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program