Provider Demographics
NPI:1962026054
Name:BALICH, GULZAR (AGPCNP)
Entity Type:Individual
Prefix:
First Name:GULZAR
Middle Name:
Last Name:BALICH
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:GULZAR
Other - Middle Name:
Other - Last Name:ISLYAMOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:2443 OCEAN AVE APT 6D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3583
Mailing Address - Country:US
Mailing Address - Phone:646-618-0863
Mailing Address - Fax:
Practice Address - Street 1:147 E 26TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-1868
Practice Address - Country:US
Practice Address - Phone:212-870-9497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY706147-1363LA2200X
NY309665363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health