Provider Demographics
NPI:1477273613
Name:SHMYRIN, NIKITA
Entity Type:Individual
Prefix:
First Name:NIKITA
Middle Name:
Last Name:SHMYRIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-1615
Mailing Address - Country:US
Mailing Address - Phone:516-595-4252
Mailing Address - Fax:
Practice Address - Street 1:21 VALLEY RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-1615
Practice Address - Country:US
Practice Address - Phone:516-595-4252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028767363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant