Provider Demographics
NPI:1164690913
Name:NATANOV, INESSA (PA)
Entity Type:Individual
Prefix:MRS
First Name:INESSA
Middle Name:
Last Name:NATANOV
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:INESSA
Other - Middle Name:
Other - Last Name:MUNAROVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:9777 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3335
Mailing Address - Country:US
Mailing Address - Phone:718-261-9100
Mailing Address - Fax:718-897-2915
Practice Address - Street 1:9785 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3319
Practice Address - Country:US
Practice Address - Phone:718-261-9100
Practice Address - Fax:718-897-2915
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011968363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011968OtherLICENSE