Basic Information
| Provider Information | |||||||||
| NPI: | 1003221193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUHL | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 MALTESE DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109402115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453424774 | ||||||||
| FaxNumber: | 8453438741 | ||||||||
| Practice Location | |||||||||
| Address1: | 249 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | NUTLEY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071102115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453424774 | ||||||||
| FaxNumber: | 8453438741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2014 | ||||||||
| LastUpdateDate: | 07/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 017609 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 25MP00348900 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 017609 | 01 | NY | NYS LICENSE | OTHER |