Healthcare Provider Details

I. General information

NPI: 1164865911
Provider Name (Legal Business Name): THE SPINE AND PAIN INSTITUTE OF NEW YORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 04/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1534 VICTORY BLVD
STATEN ISLAND NY
10314-3548
US

IV. Provider business mailing address

1534 VICTORY BLVD
STATEN ISLAND NY
10314-3548
US

V. Phone/Fax

Practice location:
  • Phone: 718-667-3577
  • Fax:
Mailing address:
  • Phone: 718-667-3577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number33337627
License Number StateNY

VIII. Authorized Official

Name: MRS. IRINA DYNOV
Title or Position: NURSE PRACTITIONER
Credential: FNP
Phone: 718-667-3577