Healthcare Provider Details

I. General information

NPI: 1356005425
Provider Name (Legal Business Name): RODSHEL NISANOV FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2021
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14146 72ND DR
FLUSHING NY
11367-2313
US

IV. Provider business mailing address

14146 72ND DR
FLUSHING NY
11367-2313
US

V. Phone/Fax

Practice location:
  • Phone: 646-525-5965
  • Fax:
Mailing address:
  • Phone: 646-525-5965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number747551
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number347908
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberF347908-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: