Provider Demographics
NPI:1972829133
Name:RAFAILOV, HELLENA (PA)
Entity Type:Individual
Prefix:
First Name:HELLENA
Middle Name:
Last Name:RAFAILOV
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 1:441 9TH AVE
Mailing Address - Street 2:CREDENTIALING 3RD FL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-1623
Mailing Address - Country:US
Mailing Address - Phone:646-680-2894
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:1050 CLOVE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3627
Practice Address - Country:US
Practice Address - Phone:718-816-6440
Practice Address - Fax:718-816-3115
Is Sole Proprietor?:No
Enumeration Date:2010-04-13
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013910-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03555653Medicaid
NY03555653Medicaid