Provider Demographics
NPI:1063227734
Name:AXELSEN, RICHARD (PA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:AXELSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 SEABROOK LN
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-3323
Mailing Address - Country:US
Mailing Address - Phone:631-689-1543
Mailing Address - Fax:
Practice Address - Street 1:740 S MEADOW ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5377
Practice Address - Country:US
Practice Address - Phone:607-319-4563
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032348363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant