=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326698572
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLIVE RICKETTS II PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2019
-----------------------------------------------------
Last Update Date | 07/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1468 MADISON AVE
-----------------------------------------------------
City | NEW YORK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10029-6508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-537-8731
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 JUPITER RD
-----------------------------------------------------
City | HIGHLAND MILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10930-2917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-831-4963
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 023928-01
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------