Provider Demographics
NPI:1891027405
Name:BOGOMOLNY, DMITRY (RPA-C)
Entity Type:Individual
Prefix:
First Name:DMITRY
Middle Name:
Last Name:BOGOMOLNY
Suffix:
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:635 W 165TH ST
Mailing Address - Street 2:BOX 435
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-3724
Mailing Address - Country:US
Mailing Address - Phone:212-305-3015
Mailing Address - Fax:
Practice Address - Street 1:635 W 165TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3724
Practice Address - Country:US
Practice Address - Phone:212-305-3015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-06
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013776-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant