Healthcare Provider Details

I. General information

NPI: 1871933515
Provider Name (Legal Business Name): LUIS ANGEL RIQUELME III
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2013
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-3208
US

IV. Provider business mailing address

16 WESTMINSTER LN
WEST ISLIP NY
11795-2620
US

V. Phone/Fax

Practice location:
  • Phone: 631-358-1201
  • Fax: 631-444-8850
Mailing address:
  • Phone: 631-747-2526
  • Fax: 631-444-8850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number016630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: