Provider Demographics
NPI:1407458466
Name:MIRSAIDOVA, DIYORA (PA)
Entity Type:Individual
Prefix:
First Name:DIYORA
Middle Name:
Last Name:MIRSAIDOVA
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 1:2935 OCEAN PKWY APT 2E
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-8042
Mailing Address - Country:US
Mailing Address - Phone:134-720-6728
Mailing Address - Fax:
Practice Address - Street 1:589 3RD AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-2711
Practice Address - Country:US
Practice Address - Phone:212-530-2288
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:No
Enumeration Date:2020-11-13
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NY026456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant