Provider Demographics
NPI:1205302593
Name:PATEL, KEVIN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:PATEL
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753-2134
Mailing Address - Country:US
Mailing Address - Phone:516-597-5070
Mailing Address - Fax:
Practice Address - Street 1:555 N BROADWAY
Practice Address - Street 2:
Practice Address - City:JERICHO
Practice Address - State:NY
Practice Address - Zip Code:11753-2134
Practice Address - Country:US
Practice Address - Phone:516-597-5070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-15
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022935363A00000X
NY363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05606139Medicaid