Provider Demographics
NPI:1134405632
Name:EDINGTON, JEREMIAH CARROL (RPA-C)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:CARROL
Last Name:EDINGTON
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:ELLICOTTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14731-0500
Mailing Address - Country:US
Mailing Address - Phone:631-475-3900
Mailing Address - Fax:
Practice Address - Street 1:1228 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2677
Practice Address - Country:US
Practice Address - Phone:631-603-3400
Practice Address - Fax:631-603-3401
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05937706Medicaid