=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073207387
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIN MARIE RUIZ PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2023
-----------------------------------------------------
Last Update Date | 06/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 ROUTE 112 STE 300
-----------------------------------------------------
City | PORT JEFFERSON STATION
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11776-3386
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-364-9119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2319 MILL RD
-----------------------------------------------------
City | RONKONKOMA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11779-1406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-848-6964
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 029974
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------