Provider Demographics
NPI:1477243913
Name:FUZAILOV, BORUCH (RN)
Entity Type:Individual
Prefix:
First Name:BORUCH
Middle Name:
Last Name:FUZAILOV
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15340 78TH AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-3439
Mailing Address - Country:US
Mailing Address - Phone:917-601-3242
Mailing Address - Fax:
Practice Address - Street 1:15340 78TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-3439
Practice Address - Country:US
Practice Address - Phone:917-601-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY870651163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health