Provider Demographics
NPI:1538392352
Name:KREEL, ROBERT ETHAN (PA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ETHAN
Last Name:KREEL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 GRAND STREET, 3RD FL
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1035
Mailing Address - Country:US
Mailing Address - Phone:845-368-5000
Mailing Address - Fax:845-987-5979
Practice Address - Street 1:28 SAGAMORE AVE
Practice Address - Street 2:
Practice Address - City:SUFFERN
Practice Address - State:NY
Practice Address - Zip Code:10901-7211
Practice Address - Country:US
Practice Address - Phone:845-357-1957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006264363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant