Provider Demographics
NPI:1174670319
Name:SHAMALOV, GENNADIY (PA)
Entity Type:Individual
Prefix:
First Name:GENNADIY
Middle Name:
Last Name:SHAMALOV
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141-23 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2930
Mailing Address - Country:US
Mailing Address - Phone:917-709-4733
Mailing Address - Fax:718-559-4895
Practice Address - Street 1:141-23 HOOVER AVE
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-1604
Practice Address - Country:US
Practice Address - Phone:917-709-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008219-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP65628Medicare UPIN