Provider Demographics
NPI:1255358164
Name:KHANUKAYEVA, RENA
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:KHANUKAYEVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 DUMONT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1450
Mailing Address - Country:US
Mailing Address - Phone:718-980-3232
Mailing Address - Fax:718-980-3233
Practice Address - Street 1:34 DUMONT AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1450
Practice Address - Country:US
Practice Address - Phone:718-980-3232
Practice Address - Fax:718-980-3233
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212257207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02010997Medicaid
NY13V161Medicare PIN
NYH07856Medicare UPIN