MEDICARE: SVETLANA ILYASOVA

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	363A00000X	Physician Assistant	013789	NY

General Provider Information

NPI Number	:	1467782672
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SVETLANA ILYASOVA

Provider Business Mailing Address
First Line	:	5645 MAINSTREET
Second Line	:
City	:	QUEENS
State	:	NY
Zip	:	11355
Country	:	US
Telephone Number	:	718-670-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	6360 98TH ST APT D16
Second Line	:
City	:	REGO PARK
State	:	NY
Zip	:	11374-2218
Country	:	US
Telephone Number	:	646-286-8952
Fax Number	:

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

Provider Enumeration Date	:	01/11/2010
Last Update Date	:	10/30/2024

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