Provider Demographics
NPI:1952999088
Name:KINGSLEY, ERIC PAUL (PA)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:PAUL
Last Name:KINGSLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 GALEN ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-4515
Mailing Address - Country:US
Mailing Address - Phone:857-304-2444
Mailing Address - Fax:
Practice Address - Street 1:2307 W BROWARD BLVD STE 200
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1420
Practice Address - Country:US
Practice Address - Phone:954-739-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-05
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical