Healthcare Provider Details

I. General information

NPI: 1508992017
Provider Name (Legal Business Name): RAVI R SALICKRAM RPA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 TOMPKINS AVE
STATEN ISLAND NY
10305-1745
US

IV. Provider business mailing address

554 TOMPKINS AVE
STATEN ISLAND NY
10305-1745
US

V. Phone/Fax

Practice location:
  • Phone: 347-855-7284
  • Fax: 631-883-8496
Mailing address:
  • Phone: 347-855-7284
  • Fax: 631-883-8496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberP54318
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number012971
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: