Healthcare Provider Details

I. General information

NPI: 1417350604
Provider Name (Legal Business Name): MAKSIM REPKA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 12/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE DIAGNOSTIC CARDIOLOGY
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

475 SEAVIEW AVE DIAGNOSTIC CARDIOLOGY
STATEN ISLAND NY
10305-3436
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-9490
  • Fax: 718-226-1946
Mailing address:
  • Phone: 718-226-9490
  • Fax: 718-226-1946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number338650
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: