Provider Demographics
NPI:1700511920
Name:MARDUKHAYEV, RAFOIL (PA-C)
Entity Type:Individual
Prefix:
First Name:RAFOIL
Middle Name:
Last Name:MARDUKHAYEV
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:RAFAEL
Other - Middle Name:
Other - Last Name:MARDUKHAYEV
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:1680 OCEAN AVE APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-4912
Mailing Address - Country:US
Mailing Address - Phone:347-759-1011
Mailing Address - Fax:
Practice Address - Street 1:100 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1850
Practice Address - Country:US
Practice Address - Phone:212-434-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-21
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NY028658363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical