MEDICARE: MUTRIBAKHON SOBIROVA

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	817301	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	123456	OTHER	NY	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1720650591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MUTRIBAKHON SOBIROVA

Provider Business Mailing Address
First Line	:	2170 E 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-5571
Country	:	US
Telephone Number	:	347-554-9074
Fax Number	:

Provider Business Practice Location Address
First Line	:	2170 E 9TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11223-5571
Country	:	US
Telephone Number	:	347-554-9074
Fax Number	:

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

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	07/12/2021

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Directions to “ MUTRIBAKHON SOBIROVA ” Practice Location

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