=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851368138
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MILTON J OCONNELL RPA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2006
-----------------------------------------------------
Last Update Date | 02/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2255 PLATTE CLOVE RD
-----------------------------------------------------
City | ELKA PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12427-1014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 845-658-7763
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2255 PLATTE CLOVE ROAD ESOPUS MEDICAL, PC
-----------------------------------------------------
City | ELKA PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-589-6178
-----------------------------------------------------
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 | MA053471
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 010238
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------