Healthcare Provider Details

I. General information

NPI: 1467061648
Provider Name (Legal Business Name): ALEXANDER JOHN KEKLIK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4A DEVINE ST
NORTH HAVEN CT
06473-2142
US

IV. Provider business mailing address

20 YORK ST
NEW HAVEN CT
06510-3220
US

V. Phone/Fax

Practice location:
  • Phone: 203-287-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number4925
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: