Provider Demographics
NPI:1215056221
Name:SIEWERS, KEVIN BOYD (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:BOYD
Last Name:SIEWERS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 EDGEWATER ST
Mailing Address - Street 2:SUITE 723
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-4900
Mailing Address - Country:US
Mailing Address - Phone:718-226-1008
Mailing Address - Fax:718-226-1039
Practice Address - Street 1:475 SEAVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-3436
Practice Address - Country:US
Practice Address - Phone:718-226-6279
Practice Address - Fax:718-226-8144
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR10708000363LP0808X
NYF400287363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1AB21ZYTP1Medicare PIN
NYWZYTP1Medicare PIN