Provider Demographics
NPI:1003645144
Name:KETTENRING, JASON
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KETTENRING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14517 17TH RD
Mailing Address - Street 2:
Mailing Address - City:WHITESTONE
Mailing Address - State:NY
Mailing Address - Zip Code:11357-3026
Mailing Address - Country:US
Mailing Address - Phone:347-756-2728
Mailing Address - Fax:
Practice Address - Street 1:177 FT WASHINGTN AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant