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General NPI Number Information
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NPI Number | 1609285329
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Entity Type | Individual
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Provider Name | EITAN ILYAYEV (PA)
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Gender | Male
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/11/2014
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Provider Practice Location Address
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Address Line | 9819 64TH AVE APT 4G
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City | REGO PARK
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State | NY
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Zip | 11374-2526
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Country | US
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Telephone | 718-483-2731
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Fax |
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Provider Business Mailing Address
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Address Line | 9819 64TH AVE APT 4G
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City | REGO PARK
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State | NY
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Zip | 11374-2526
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Country | US
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Telephone | 718-483-2731
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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 | 017825
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License Number State | NY
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