Healthcare Provider Details

I. General information

NPI: 1770099681
Provider Name (Legal Business Name): YURI YAKUBOV CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WOODS RD
VALHALLA NY
10595-1530
US

IV. Provider business mailing address

230 174TH ST APT 1101
SUNNY ISLES BEACH FL
33160-3330
US

V. Phone/Fax

Practice location:
  • Phone: 914-493-7000
  • Fax:
Mailing address:
  • Phone: 347-634-6050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number652056
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11042361
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: