Provider Demographics
NPI:1639370554
Name:RENA KHANUKAYEVA D.O.,P.C.
Entity Type:Organization
Organization Name:RENA KHANUKAYEVA D.O.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RENA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANUKAYEVA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-980-3232
Mailing Address - Street 1:2691 HYLAN BLVD
Mailing Address - Street 2:SUITE # 5
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3231
Mailing Address - Country:US
Mailing Address - Phone:718-980-3232
Mailing Address - Fax:
Practice Address - Street 1:2691 HYLAN BLVD
Practice Address - Street 2:SUITE # 5
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-4300
Practice Address - Country:US
Practice Address - Phone:718-980-3232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212257261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWZYTQ1Medicare PIN