Provider Demographics
NPI:1952897217
Name:FUZAYLOVA, NATELLA (PA)
Entity type:Individual
Prefix:
First Name:NATELLA
Middle Name:
Last Name:FUZAYLOVA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 E AMES CT
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-2317
Mailing Address - Country:US
Mailing Address - Phone:151-641-4586
Mailing Address - Fax:
Practice Address - Street 1:16303 HORACE HARDING EXPY RM 300
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1449
Practice Address - Country:US
Practice Address - Phone:718-464-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0144015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant