Provider Demographics
NPI:1316175052
Name:LE ROY, KEVIN T (CFNP)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:LE ROY
Suffix:
Gender:M
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3807
Mailing Address - Country:US
Mailing Address - Phone:315-452-2333
Mailing Address - Fax:315-452-2336
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-349-5511
Practice Address - Fax:315-349-5732
Is Sole Proprietor?:No
Enumeration Date:2009-07-01
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY335967207P00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03133180Medicaid
NY03133180Medicaid
NYJ400005248Medicare PIN