Provider Demographics
NPI:1558078444
Name:RILEY, JEFFREY KEVIN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KEVIN
Last Name:RILEY
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 1:2124 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-6229
Mailing Address - Country:US
Mailing Address - Phone:718-986-4616
Mailing Address - Fax:
Practice Address - Street 1:955 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1738
Practice Address - Country:US
Practice Address - Phone:212-734-9949
Practice Address - Fax:212-734-9894
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
028598363A00000X
NY028598363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant