Provider Demographics
NPI:1164865911
Name:THE SPINE AND PAIN INSTITUTE OF NEW YORK
Entity Type:Organization
Organization Name:THE SPINE AND PAIN INSTITUTE OF NEW YORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:IRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:DYNOV
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:718-667-3577
Mailing Address - Street 1:1534 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3548
Mailing Address - Country:US
Mailing Address - Phone:718-667-3577
Mailing Address - Fax:
Practice Address - Street 1:1534 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3548
Practice Address - Country:US
Practice Address - Phone:718-667-3577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33337627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty