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General NPI Number Information
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NPI Number | 1144493578
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Entity Type | Individual
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Provider Name | LILIA YAKUTELOV PA
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Gender | Female
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Dates
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Enumeration Date | 04/07/2008
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Last Update Date | 10/06/2014
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Provider Practice Location Address
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Address Line | 410 LAKEVILLE RD
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City | NEW HYDE PARK
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State | NY
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Zip | 11042-1101
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Country | US
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Telephone | 718-470-8784
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Fax |
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Provider Business Mailing Address
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Address Line | 8318 HOMELAWN ST
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City | JAMAICA
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State | NY
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Zip | 11432-2150
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 012487
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 059737
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License Number State | NY
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