Healthcare Provider Details

I. General information

NPI: 1003180803
Provider Name (Legal Business Name): KENNETH BOMPAROLA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 03/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1901 1ST AVE
NEW YORK NY
10029-7404
US

IV. Provider business mailing address

316 CARNATION RD
WEST ISLIP NY
11795-2802
US

V. Phone/Fax

Practice location:
  • Phone: 212-423-6262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number015373
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: