Provider Demographics
NPI:1689925091
Name:KHOLDAROVA, RAKHILYA (PA)
Entity Type:Individual
Prefix:
First Name:RAKHILYA
Middle Name:
Last Name:KHOLDAROVA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3757 91ST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11372-7901
Mailing Address - Country:US
Mailing Address - Phone:718-779-7697
Mailing Address - Fax:
Practice Address - Street 1:3757 91ST ST
Practice Address - Street 2:
Practice Address - City:JACKSON HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11372-7901
Practice Address - Country:US
Practice Address - Phone:718-779-7697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015962363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical