Provider Demographics
NPI:1568550150
Name:CUNNINGHAM, KEVIN J (PA)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:CUNNINGHAM
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:972 BRUSH HOLLOW RD
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-1740
Mailing Address - Country:US
Mailing Address - Phone:516-876-5555
Mailing Address - Fax:516-876-5539
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-4761
Practice Address - Fax:516-562-1521
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY010965363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
E74896Medicare UPIN