Healthcare Provider Details

I. General information

NPI: 1750070892
Provider Name (Legal Business Name): KRISTA MARIE KEDL MS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2023
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CAMPUS RD
STATEN ISLAND NY
10301-4479
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD STE 220
RED BANK NJ
07701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 718-319-3100
  • Fax:
Mailing address:
  • Phone: 732-807-0877
  • Fax: 201-751-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00818300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: