Provider Demographics
NPI:1396762191
Name:KATANOV, JACOB (PA)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KATANOV
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2202 STEINWAY ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-1836
Mailing Address - Country:US
Mailing Address - Phone:718-423-0808
Mailing Address - Fax:718-204-6866
Practice Address - Street 1:540 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1985
Practice Address - Country:US
Practice Address - Phone:718-855-4900
Practice Address - Fax:718-802-0631
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY007935363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ27769Medicare UPIN