Provider Demographics
NPI:1316064124
Name:KINGSTON, STEPHEN JOHN II (PA-C)
Entity type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:JOHN
Last Name:KINGSTON
Suffix:II
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 PENFIELD RD
Mailing Address - Street 2:APT 85
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-2148
Mailing Address - Country:US
Mailing Address - Phone:585-264-1454
Mailing Address - Fax:
Practice Address - Street 1:ROUTE 96
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:NY
Practice Address - Zip Code:14541-0400
Practice Address - Country:US
Practice Address - Phone:607-869-5111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008910363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ27616Medicare UPIN