Provider Demographics
NPI:1396454435
Name:O'CONNOR, KEVIN J (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:267 E MAIN ST BLDG C
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2847
Mailing Address - Country:US
Mailing Address - Phone:631-418-8069
Mailing Address - Fax:631-656-0470
Practice Address - Street 1:267 E MAIN ST BLDG C
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2847
Practice Address - Country:US
Practice Address - Phone:316-418-8069
Practice Address - Fax:631-656-0470
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2024-02-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY530505163W00000X
NYF352584-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse