Provider Demographics
NPI:1881004984
Name:KUSIK, KELLY (PA)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KUSIK
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 9TH AVE
Mailing Address - Street 2:ACPNY - CREDENTIALING 3RD FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1602
Mailing Address - Country:US
Mailing Address - Phone:646-680-2894
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:150 55TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-2508
Practice Address - Country:US
Practice Address - Phone:718-630-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400134631Medicare PIN