Provider Demographics
NPI:1063459048
Name:BRODSKAYA, YEVGENIYA (PA)
Entity Type:Individual
Prefix:
First Name:YEVGENIYA
Middle Name:
Last Name:BRODSKAYA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5205 CHURCH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-3513
Mailing Address - Country:US
Mailing Address - Phone:718-688-6000
Mailing Address - Fax:718-385-5104
Practice Address - Street 1:5205 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-3513
Practice Address - Country:US
Practice Address - Phone:718-688-6000
Practice Address - Fax:718-385-5104
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYMB1476743OtherDEA #