Basic Information
| Provider Information | |||||||||
| NPI: | 1578912325 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUDYAKOV | ||||||||
| FirstName: | RENAT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7777 FOREST LN STE B446 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752305647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725668822 | ||||||||
| FaxNumber: | 9725668861 | ||||||||
| Practice Location | |||||||||
| Address1: | 7777 FOREST LN STE B446 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752305647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9725668822 | ||||||||
| FaxNumber: | 9725668861 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2016 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 340648 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | AP137445 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | AP137445 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.