Healthcare Provider Details

I. General information

NPI: 1881920502
Provider Name (Legal Business Name): IRINA ILYASOV RPA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8686 BAY PKWY STE M4
BROOKLYN NY
11214-5103
US

IV. Provider business mailing address

62 KEUNE CT
STATEN ISLAND NY
10304-1431
US

V. Phone/Fax

Practice location:
  • Phone: 718-265-7700
  • Fax: 718-265-7701
Mailing address:
  • Phone: 718-265-7700
  • Fax: 718-265-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number013442
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: