Healthcare Provider Details

I. General information

NPI: 1659176899
Provider Name (Legal Business Name): KEVIN LLIGUISUPA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2025
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1752 FRANCIS LEWIS BLVD
WHITESTONE NY
11357-3247
US

IV. Provider business mailing address

1752 FRANCIS LEWIS BLVD
WHITESTONE NY
11357-3247
US

V. Phone/Fax

Practice location:
  • Phone: 718-746-9494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number033239
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: