Provider Demographics
NPI:1083127799
Name:YANISHIN, YAROSLAV
Entity Type:Individual
Prefix:
First Name:YAROSLAV
Middle Name:
Last Name:YANISHIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5812 79TH ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLE VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11379-5312
Mailing Address - Country:US
Mailing Address - Phone:718-541-1262
Mailing Address - Fax:
Practice Address - Street 1:229 7TH ST STE 105
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-5766
Practice Address - Country:US
Practice Address - Phone:516-747-7778
Practice Address - Fax:516-517-9533
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X, 390200000X
NY023817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program