Healthcare Provider Details

I. General information

NPI: 1790459816
Provider Name (Legal Business Name): KEVIN JARAMILLO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 PARKVIEW TER APT 39
ENGLEWOOD NJ
07631-4214
US

IV. Provider business mailing address

16-12 FAR ROCKAWAY BLVD
FAR ROCKAWAY NY
11691
US

V. Phone/Fax

Practice location:
  • Phone: 201-674-8415
  • 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 TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00760900
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number2745644
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: