Provider Demographics
NPI:1104866557
Name:KALANTAROVA, IRINA (PA)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KALANTAROVA
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:PO BOX 1471
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-1471
Mailing Address - Country:US
Mailing Address - Phone:800-795-5820
Mailing Address - Fax:
Practice Address - Street 1:7035 113TH ST
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4651
Practice Address - Country:US
Practice Address - Phone:718-990-4648
Practice Address - Fax:718-990-4414
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008566363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00392222OtherRAILROAD
NYP00403315OtherRAILROAD
NYP00403315OtherRAILROAD
NYP60290Medicare UPIN
NY6510HDMedicare PIN