Provider Demographics
NPI:1285117598
Name:RILEY, KEVIN CONSTANTINE (NP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:CONSTANTINE
Last Name:RILEY
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 1:592 ROCKAWAY AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11212-5539
Mailing Address - Country:US
Mailing Address - Phone:718-345-6366
Mailing Address - Fax:
Practice Address - Street 1:650 ASHFORD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11207
Practice Address - Country:US
Practice Address - Phone:347-505-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-12
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340120-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily