Provider Demographics
NPI:1871933515
Name:RIQUELME, LUIS ANGEL III
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ANGEL
Last Name:RIQUELME
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 WESTMINSTER LN
Mailing Address - Street 2:
Mailing Address - City:WEST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11795-2620
Mailing Address - Country:US
Mailing Address - Phone:631-747-2526
Mailing Address - Fax:631-444-8850
Practice Address - Street 1:101 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3208
Practice Address - Country:US
Practice Address - Phone:631-358-1201
Practice Address - Fax:631-444-8850
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-26
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016630363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical