Healthcare Provider Details

I. General information

NPI: 1538247077
Provider Name (Legal Business Name): JEAN-BAPTISTE KERROLD RICHARD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2057
US

IV. Provider business mailing address

535 DAVIE ST
WESTBURY NY
11590-5955
US

V. Phone/Fax

Practice location:
  • Phone: 718-245-4748
  • Fax:
Mailing address:
  • Phone: 646-245-9125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number010406
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: