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NPI Code Detail

MEDICARE: MR. OTABEK PULATOV PA-C

MEDICARE: MR. OTABEK PULATOV PA-C
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
1363AM0700XMedical Physician Assistant

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11151097OTHERNCCPA ID

General Provider Information

NPI Number : 1699276618
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. OTABEK PULATOV PA-C
Provider Business Mailing Address
First Line : 2940 OCEAN PARKWAY
Second Line : 20D
City : BROOKYLN
State : NY
Zip : 11235
Country : US
Telephone Number : 347-586-7775
Fax Number :
Provider Business Practice Location Address
First Line : 3311 HYLAN BLVD
Second Line :
City : STATEN ISLAND
State : NY
Zip : 10306-3611
Country : US
Telephone Number : 718-667-7500
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/25/2018
Last Update Date : 03/17/2018

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