Provider Demographics
NPI:1912057787
Name:IRININA, TATYANA (DPT)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:IRININA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 EDISON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3410
Mailing Address - Country:US
Mailing Address - Phone:917-977-1067
Mailing Address - Fax:
Practice Address - Street 1:520 BLOOMINGDALE RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-2061
Practice Address - Country:US
Practice Address - Phone:718-605-1300
Practice Address - Fax:718-615-8739
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023912225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000218970101OtherHEALTH PLUS
NYQM9301Medicare ID - Type UnspecifiedPROVIDER