Provider Demographics
NPI:1295324051
Name:YAKUBOV, IGOR (FNP)
Entity type:Individual
Prefix:
First Name:IGOR
Middle Name:
Last Name:YAKUBOV
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10853 62ND DR APT 6E
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-1221
Mailing Address - Country:US
Mailing Address - Phone:917-345-5555
Mailing Address - Fax:
Practice Address - Street 1:10853 62ND DR APT 6E
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11375-1221
Practice Address - Country:US
Practice Address - Phone:917-345-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-14
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY717225163W00000X
NY351240363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty