Basic Information
| Provider Information | |||||||||
| NPI: | 1285117598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RILEY | ||||||||
| FirstName: | KEVIN | ||||||||
| MiddleName: | CONSTANTINE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 592 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183456366 | ||||||||
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| Practice Location | |||||||||
| Address1: | 650 ASHFORD ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475051800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2018 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F340120-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.