Provider Demographics
NPI:1043477318
Name:YUSHUVAYEV, EDUARD (PA)
Entity Type:Individual
Prefix:
First Name:EDUARD
Middle Name:
Last Name:YUSHUVAYEV
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7339 174TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1424
Mailing Address - Country:US
Mailing Address - Phone:718-215-0020
Mailing Address - Fax:
Practice Address - Street 1:4500 PARSONS BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-2205
Practice Address - Country:US
Practice Address - Phone:718-670-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011719363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011719OtherNEW YORK STATE LICENSE
NY011719OtherNEW YORK STATE LICENSE