Healthcare Provider Details

I. General information

NPI: 1851854046
Provider Name (Legal Business Name): ROMAN DZHURAYEV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2019
Last Update Date: 04/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8911 63RD DR APT 425
REGO PARK NY
11374-3841
US

IV. Provider business mailing address

8911 63RD DR APT 425
REGO PARK NY
11374-3841
US

V. Phone/Fax

Practice location:
  • Phone: 646-705-5387
  • Fax:
Mailing address:
  • Phone: 646-705-5487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number309120
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: