Provider Demographics
NPI:1063785863
Name:NISENBOYM, MAKSIM (PA)
Entity type:Individual
Prefix:
First Name:MAKSIM
Middle Name:
Last Name:NISENBOYM
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14755 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-2139
Mailing Address - Country:US
Mailing Address - Phone:718-523-5674
Mailing Address - Fax:
Practice Address - Street 1:14755 HOOVER AVE
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-2139
Practice Address - Country:US
Practice Address - Phone:718-523-5674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015471363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant