Healthcare Provider Details

I. General information

NPI: 1881865533
Provider Name (Legal Business Name): ABO SUYONOV PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 11/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 HICKVILLE ROAD 259 1ST STREET
MINEOLA NY
11501
US

IV. Provider business mailing address

700 HICKSVILLE RD SUITE 204
BETHPAGE NY
11714-3471
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-8312
  • Fax: 516-663-2184
Mailing address:
  • Phone: 516-576-6106
  • Fax: 516-576-5801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601008481
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011213
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: