Provider Demographics
NPI:1508233503
Name:GULAMOV, DAVID KHAYIM (PA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:KHAYIM
Last Name:GULAMOV
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 1:9841 65TH AVE
Mailing Address - Street 2:3D
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3450
Mailing Address - Country:US
Mailing Address - Phone:917-656-1112
Mailing Address - Fax:
Practice Address - Street 1:9841 65TH AVE
Practice Address - Street 2:3D
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3450
Practice Address - Country:US
Practice Address - Phone:917-656-1112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018898363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant