=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003689472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ULKAR GARAYEV
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2023
-----------------------------------------------------
Last Update Date | 11/06/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1854 HYLAN BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10305-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-533-0424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 ADRIENNE AVE
-----------------------------------------------------
City | STEWARTSVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08886-3264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-453-0222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | 3081119
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 3081119
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------