Basic Information
| Provider Information | |||||||||
| NPI: | 1629362439 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YUSUPOV | ||||||||
| FirstName: | EMANUEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79-01 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183341921 | ||||||||
| FaxNumber: | 7183345958 | ||||||||
| Practice Location | |||||||||
| Address1: | 79-01 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11373 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183341921 | ||||||||
| FaxNumber: | 7183345958 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2011 | ||||||||
| LastUpdateDate: | 06/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 014745 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.