Provider Demographics
NPI:1972746196
Name:RUBINOV, MARINA (PA)
Entity Type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:RUBINOV
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:112 05 QUEENS BLVD GROUND FLOOR
Mailing Address - Street 2:FOREST HILLS
Mailing Address - City:QUEENS
Mailing Address - State:NY
Mailing Address - Zip Code:11375
Mailing Address - Country:US
Mailing Address - Phone:718-303-3725
Mailing Address - Fax:718-886-4215
Practice Address - Street 1:11205 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-8311
Practice Address - Country:US
Practice Address - Phone:718-830-1030
Practice Address - Fax:718-886-4251
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007627207VX0201X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01871452Medicaid
NONEOtherNONE