Provider Demographics
NPI:1013654854
Name:GERASIMOVICH, KENNETH ADAM
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:ADAM
Last Name:GERASIMOVICH
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 1:11 WILLOW PL
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1561
Mailing Address - Country:US
Mailing Address - Phone:516-528-0194
Mailing Address - Fax:
Practice Address - Street 1:11 WILLOW PL
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1561
Practice Address - Country:US
Practice Address - Phone:516-528-0194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-13
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant