=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093131856
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIMONSARKIS ULUBABOV R.N.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2014
-----------------------------------------------------
Last Update Date | 04/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 HEMPSTEAD TPKE
-----------------------------------------------------
City | EAST MEADOW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11554-1859
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-572-6066
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1233 FATHER CAPODANNO BLVD
-----------------------------------------------------
City | STATEN ISLAND
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10306-6061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-213-3226
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0705X
-----------------------------------------------------
Taxonomy Name | Medical-Surgical Registered Nurse
-----------------------------------------------------
License Number | 663047
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 310817
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------