=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477514644
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLEG A VISHNYAK PAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2006
-----------------------------------------------------
Last Update Date | 05/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 270-05 76TH AVE SUITE 0-4000
-----------------------------------------------------
City | NEW HYDE PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-470-7460
-----------------------------------------------------
Fax | 718-343-1438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1915 SEAGIRT BLVD APT 12F
-----------------------------------------------------
City | FAR ROCKWAY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11691
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-471-7833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 010656
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------