Provider Demographics
NPI:1023188059
Name:MYCHAJLYSZYN, JOLANTA (RPA-C)
Entity Type:Individual
Prefix:
First Name:JOLANTA
Middle Name:
Last Name:MYCHAJLYSZYN
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E GATE BLVD STE 111
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2124
Mailing Address - Country:US
Mailing Address - Phone:516-804-5200
Mailing Address - Fax:516-240-6540
Practice Address - Street 1:2000 N VILLAGE AVE
Practice Address - Street 2:SUITE 402
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570
Practice Address - Country:US
Practice Address - Phone:516-766-2519
Practice Address - Fax:516-766-3714
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007260-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5F1941Medicare ID - Type UnspecifiedPROVIDER ID#
NYP57178Medicare UPIN