Healthcare Provider Details

I. General information

NPI: 1851121610
Provider Name (Legal Business Name): PAVEL ODINTSOV NP IN ADULT HEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 S MAIN ST STE 106
NEW CITY NY
10956-3318
US

IV. Provider business mailing address

297 HILLSDALE AVE
HILLSDALE NJ
07642-2212
US

V. Phone/Fax

Practice location:
  • Phone: 845-358-4000
  • Fax:
Mailing address:
  • Phone: 201-665-4150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: PAVEL ODINTSOV
Title or Position: OWNER/NURSE PRACTITIONER
Credential: ADULT-NP., PMHNP.
Phone: 201-665-4150