Provider Demographics
NPI:1609285329
Name:ILYAYEV, EITAN ((PA))
Entity Type:Individual
Prefix:
First Name:EITAN
Middle Name:
Last Name:ILYAYEV
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 1:9819 64TH AVE APT 4G
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2526
Mailing Address - Country:US
Mailing Address - Phone:718-483-2731
Mailing Address - Fax:
Practice Address - Street 1:9819 64TH AVE APT 4G
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2526
Practice Address - Country:US
Practice Address - Phone:718-483-2731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-06
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017825363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical