Provider Demographics
NPI:1518477306
Name:GUKETLOV, RACHEL (PA-C)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:
Last Name:GUKETLOV
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 1:97 GASKIN AVE
Mailing Address - Street 2:
Mailing Address - City:SPOTSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08884-1183
Mailing Address - Country:US
Mailing Address - Phone:732-501-2876
Mailing Address - Fax:
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:212-639-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00456200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program