Provider Demographics
NPI:1881920502
Name:ILYASOV, IRINA (RPA-C)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:ILYASOV
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 KEUNE CT
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1431
Mailing Address - Country:US
Mailing Address - Phone:718-265-7700
Mailing Address - Fax:718-265-7701
Practice Address - Street 1:8686 BAY PKWY
Practice Address - Street 2:STE M4
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-5103
Practice Address - Country:US
Practice Address - Phone:718-265-7700
Practice Address - Fax:718-265-7701
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-30
Last Update Date:2009-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013442363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical