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General NPI Number Information
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NPI Number | 1467782672
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Entity Type | Individual
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Provider Name | SVETLANA ILYASOVA
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Gender | Female
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Dates
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Enumeration Date | 01/11/2010
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 6360 98TH ST APT D16
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City | REGO PARK
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State | NY
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Zip | 11374-2218
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Country | US
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Telephone | 646-286-8952
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Fax |
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Provider Business Mailing Address
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Address Line | 5645 MAINSTREET
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City | QUEENS
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State | NY
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Zip | 11355
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Country | US
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Telephone | 718-670-2000
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 013789
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License Number State | NY
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