Healthcare Provider Details

I. General information

NPI: 1114209954
Provider Name (Legal Business Name): KIMBERLY EVA SEWNARINE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2011
Last Update Date: 09/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3451 9TH ST 1B
LONG ISLAND CITY NY
11106-5161
US

IV. Provider business mailing address

PO BOX 6465
LONG ISLAND CITY NY
11106-0465
US

V. Phone/Fax

Practice location:
  • Phone: 718-578-8578
  • Fax:
Mailing address:
  • Phone: 718-578-8578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015062
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: