Healthcare Provider Details

I. General information

NPI: 1992155121
Provider Name (Legal Business Name): IGA AIZIGOV FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2016
Last Update Date: 10/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50653 HOLLYBROOK DR
GRANGER IN
46530-4947
US

IV. Provider business mailing address

50653 HOLLYBROOK DR
GRANGER IN
46530-4947
US

V. Phone/Fax

Practice location:
  • Phone: 718-208-0510
  • Fax:
Mailing address:
  • Phone: 718-208-0510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28218728A
License Number StateIN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: