MEDICARE: JACOB RAZIYEV RPA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	006457	NY

General Provider Information

NPI Number	:	1407870157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB RAZIYEV RPA-C

Provider Business Mailing Address
First Line	:	7814 271ST ST
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11040-1504
Country	:	US
Telephone Number	:	718-347-1717
Fax Number	:

Provider Business Practice Location Address
First Line	:	7815 ELIOT AVE
Second Line	:
City	:	MIDDLE VILLAGE
State	:	NY
Zip	:	11379-1300
Country	:	US
Telephone Number	:	718-458-8944
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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