1164690913 NPI number — MRS. INESSA NATANOV PA

Table of content: MRS. INESSA NATANOV PA (NPI 1164690913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164690913 NPI number — MRS. INESSA NATANOV PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NATANOV
Provider First Name:
INESSA
Provider Middle Name:
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MUNAROVA
Provider Other First Name:
INESSA
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHYSICIAN ASSISTANT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1164690913
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9777 QUEENS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
REGO PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11374-3335
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-261-9100
Provider Business Mailing Address Fax Number:
718-897-2915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9785 QUEENS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
REGO PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11374-3319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-261-9100
Provider Business Practice Location Address Fax Number:
718-897-2915
Provider Enumeration Date:
02/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  011968 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 011968 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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