Provider Demographics
NPI:1255519617
Name:KHOLODNY, IRINA (R-PAC)
Entity type:Individual
Prefix:MRS
First Name:IRINA
Middle Name:
Last Name:KHOLODNY
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:MS
Other - First Name:IRINA
Other - Middle Name:
Other - Last Name:BASOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPA-C
Mailing Address - Street 1:585 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758
Mailing Address - Country:US
Mailing Address - Phone:516-797-2146
Mailing Address - Fax:516-797-0190
Practice Address - Street 1:585 BROADWAY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758
Practice Address - Country:US
Practice Address - Phone:516-797-2146
Practice Address - Fax:516-797-0190
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006415363A00000X
NY0064151363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant