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General NPI Number Information
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NPI Number | 1881920502
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Entity Type | Individual
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Provider Name | IRINA ILYASOV RPA-C
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Gender | Female
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Dates
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Enumeration Date | 10/30/2009
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Last Update Date | 10/30/2009
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Provider Practice Location Address
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Address Line | 8686 BAY PKWY STE M4
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City | BROOKLYN
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State | NY
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Zip | 11214-5103
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Country | US
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Telephone | 718-265-7700
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Fax | 718-265-7701
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Provider Business Mailing Address
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Address Line | 62 KEUNE CT
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City | STATEN ISLAND
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State | NY
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Zip | 10304-1431
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Country | US
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Telephone | 718-265-7700
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Fax | 718-265-7701
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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 | 013442
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License Number State | NY
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