Healthcare Provider Details

I. General information

NPI: 1285071555
Provider Name (Legal Business Name): VYACHESLAV GULKAROV FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2013
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6560 BOOTH ST APT 4D
REGO PARK NY
11374-4133
US

IV. Provider business mailing address

6560 BOOTH ST APT 4D
REGO PARK NY
11374-4133
US

V. Phone/Fax

Practice location:
  • Phone: 917-640-4589
  • Fax:
Mailing address:
  • Phone: 917-640-4589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344086
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number624171-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: