Basic Information
| Provider Information | |||||||||
| NPI: | 1699276618 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PULATOV | ||||||||
| FirstName: | OTABEK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 OCEAN PARKWAY | ||||||||
| Address2: | 20D | ||||||||
| City: | BROOKYLN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11235 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475867775 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3311 HYLAN BLVD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103063611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186677500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2018 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1151097 | 01 | NCCPA ID | OTHER |