Healthcare Provider Details

I. General information

NPI: 1972741023
Provider Name (Legal Business Name): VLADISLAV KUZNETSOV PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 RIDGE LOOP
STATEN ISLAND NY
10304-1403
US

IV. Provider business mailing address

30 RIDGE LOOP
STATEN ISLAND NY
10304-1403
US

V. Phone/Fax

Practice location:
  • Phone: 917-836-7374
  • Fax: 718-865-4255
Mailing address:
  • Phone: 917-836-7374
  • Fax: 718-865-4255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007745
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: