Basic Information
| Provider Information | |||||||||
| NPI: | 1164753182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REGISTERED PHYSICIAN ASSISTANT FIRST ASSIST PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14123 HOOVER AVE | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114351109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177094733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13876 QUEENS BLVD | ||||||||
| Address2: | 1ST FLOOR | ||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2010 | ||||||||
| LastUpdateDate: | 01/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | SHAMALOV | ||||||||
| AuthorizedOfficialFirstName: | GENNADIY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 9177094733 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | RPA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 008219 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.