Provider Demographics
NPI:1811763576
Name:BAKANOV, BORIS (NP)
Entity type:Individual
Prefix:
First Name:BORIS
Middle Name:
Last Name:BAKANOV
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1660 E 66TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234
Mailing Address - Country:US
Mailing Address - Phone:718-404-8156
Mailing Address - Fax:
Practice Address - Street 1:440 W 114TH ST FL 6
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1796
Practice Address - Country:US
Practice Address - Phone:212-523-8570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF311621363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health