Provider Demographics
NPI:1245563485
Name:MUSHEKOV, TIMUR (PA)
Entity Type:Individual
Prefix:
First Name:TIMUR
Middle Name:
Last Name:MUSHEKOV
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 1:9211 101ST AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:OZONE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11416-2319
Mailing Address - Country:US
Mailing Address - Phone:917-628-7062
Mailing Address - Fax:
Practice Address - Street 1:600 E 233RD ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10466-2604
Practice Address - Country:US
Practice Address - Phone:718-920-9826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2009-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006730-1363AM0700X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical