MEDICARE: JONATHAN MAKSUMOV FNP

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	163W00000X	Registered Nurse	698931	NY
2	363LF0000X	Family Nurse Practitioner	344516	NY

General Provider Information

NPI Number	:	1063877082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN MAKSUMOV FNP

Provider Business Mailing Address
First Line	:	9932 65TH AVE
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374-3653
Country	:	US
Telephone Number	:	917-497-2461
Fax Number	:

Provider Business Practice Location Address
First Line	:	6405 YELLOWSTONE BLVD APT 101
Second Line	:
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-1534
Country	:	US
Telephone Number	:	718-896-3376
Fax Number	:

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

Provider Enumeration Date	:	12/17/2015
Last Update Date	:	06/19/2019

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