Healthcare Provider Details

I. General information

NPI: 1063227734
Provider Name (Legal Business Name): RICHARD AXELSEN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 S MEADOW ST
ITHACA NY
14850-5377
US

IV. Provider business mailing address

9 SEABROOK LN
STONY BROOK NY
11790-3323
US

V. Phone/Fax

Practice location:
  • Phone: 607-319-4563
  • Fax:
Mailing address:
  • Phone: 631-689-1543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number032348
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: