Provider Demographics
NPI:1831113745
Name:STILLWELL, KRISTOPHER JOHN (PA)
Entity Type:Individual
Prefix:MR
First Name:KRISTOPHER
Middle Name:JOHN
Last Name:STILLWELL
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:763 LARKFIELD RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3131
Mailing Address - Country:US
Mailing Address - Phone:631-462-2225
Mailing Address - Fax:631-462-2240
Practice Address - Street 1:763 LARKFIELD RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3131
Practice Address - Country:US
Practice Address - Phone:631-462-2225
Practice Address - Fax:631-462-2240
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY007332363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS97697Medicare UPIN