MEDICARE: YANINA ETLIS DO PC

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	207Q00000X	Family Medicine Physician	228241	NY

General Provider Information

NPI Number	:	1679595334
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YANINA ETLIS DO PC

Provider Business Mailing Address
First Line	:	3030 OCEAN AVE
Second Line	:	SUITE AA
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3363
Country	:	US
Telephone Number	:	646-250-8282
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 OCEAN AVE
Second Line	:	SUITE AA
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3363
Country	:	US
Telephone Number	:	646-250-8282
Fax Number	:	718-769-2365

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	YANINA ETLIS
Credential	:	DO
Telephone Number	:	646-250-8282

Provider Enumeration Date	:	07/24/2006
Last Update Date	:	08/22/2020

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