Basic Information
| Provider Information | |||||||||
| NPI: | 1174670319 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAMALOV | ||||||||
| FirstName: | GENNADIY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141-23 HOOVER AVE | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177094733 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Practice Location | |||||||||
| Address1: | 141-23 HOOVER AVE | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114351604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177094733 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 008219-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.