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General NPI Number Information
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NPI Number | 1174251318
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Entity Type | Individual
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Provider Name | RENAT KHASANOV MSN, PMHNP-BC, RN
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Gender | Male
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Dates
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Enumeration Date | 08/14/2022
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Last Update Date | 09/23/2022
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Provider Practice Location Address
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Address Line | 75-59 263RD STREET
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City | GLEN OAKS
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State | NY
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Zip | 11004-1100
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Country | US
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Telephone | 718-470-5750
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Fax |
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Provider Business Mailing Address
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Address Line | 2266 BATH AVE # 3010
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City | BROOKLYN
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State | NY
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Zip | 11214-5714
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Country | US
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Telephone | 917-969-6012
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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 | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 404349
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License Number State | NY
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