Provider Demographics
NPI:1164594156
Name:YAGUDAEV, AVITAL (PA)
Entity Type:Individual
Prefix:
First Name:AVITAL
Middle Name:
Last Name:YAGUDAEV
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 1:9931 64TH AVE
Mailing Address - Street 2:#B14
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2652
Mailing Address - Country:US
Mailing Address - Phone:718-897-3940
Mailing Address - Fax:
Practice Address - Street 1:15705 CROSSBAY BLVD
Practice Address - Street 2:
Practice Address - City:HOWARD BEACH
Practice Address - State:NY
Practice Address - Zip Code:11414-2748
Practice Address - Country:US
Practice Address - Phone:718-845-5252
Practice Address - Fax:718-845-6464
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009742363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical