Healthcare Provider Details

I. General information

NPI: 1417867698
Provider Name (Legal Business Name): PETR KANEVSKIY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 PARK AVE
HUNTINGTON NY
11743-2787
US

IV. Provider business mailing address

100 VILLAGE SQ APT 203
GLEN COVE NY
11542-2598
US

V. Phone/Fax

Practice location:
  • Phone: 631-351-2000
  • Fax:
Mailing address:
  • Phone: 347-342-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number788151
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number788151
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: