Basic Information
| Provider Information | |||||||||
| NPI: | 1740614445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YAKOBOV | ||||||||
| FirstName: | OLGA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | W-LL 300 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184450220 | ||||||||
| FaxNumber: | 7186617405 | ||||||||
| Practice Location | |||||||||
| Address1: | 5645 MAIN ST | ||||||||
| Address2: | W-LL 300 | ||||||||
| City: | FLUSHING | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113555045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184450220 | ||||||||
| FaxNumber: | 7186617405 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2013 | ||||||||
| LastUpdateDate: | 10/13/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 016764-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.