Healthcare Provider Details

I. General information

NPI: 1154257863
Provider Name (Legal Business Name): RAFAEL ILYAYEV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

168 BEACH 96TH ST
ROCKAWAY BEACH NY
11693-1305
US

IV. Provider business mailing address

168 BEACH 96TH ST
ROCKAWAY BEACH NY
11693-1305
US

V. Phone/Fax

Practice location:
  • Phone: 347-781-8768
  • Fax:
Mailing address:
  • Phone: 347-781-8768
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360202
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: