MEDICARE: MR. ALEXANDER KHUDYSH R.R.A

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	000179	NY

General Provider Information

NPI Number	:	1023315538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ALEXANDER KHUDYSH R.R.A

Provider Business Mailing Address
First Line	:	2815 COYLE ST APT 611
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-1742
Country	:	US
Telephone Number	:	413-636-2919
Fax Number	:

Provider Business Practice Location Address
First Line	:	2815 COYLE ST APT 611
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-1742
Country	:	US
Telephone Number	:	413-636-2919
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/17/2011
Last Update Date	:	02/17/2011

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