Provider Demographics
NPI:1164007548
Name:YUSUPOV, GEORGIY
Entity Type:Individual
Prefix:MR
First Name:GEORGIY
Middle Name:
Last Name:YUSUPOV
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:GEORGIY
Other - Middle Name:
Other - Last Name:YUSUPOV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:14020 68TH DR
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1652
Mailing Address - Country:US
Mailing Address - Phone:646-331-5198
Mailing Address - Fax:
Practice Address - Street 1:3709 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-3507
Practice Address - Country:US
Practice Address - Phone:718-444-7766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-16
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF347371-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily