Provider Demographics
NPI:1124231543
Name:ODES, LYUBOV NIKOLAEVNA (PA)
Entity type:Individual
Prefix:MS
First Name:LYUBOV
Middle Name:NIKOLAEVNA
Last Name:ODES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:LYUBOV
Other - Middle Name:NIKOLAEVNA
Other - Last Name:ODES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:440 EAST 9TH STREET
Mailing Address - Street 2:APT 6 E
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218
Mailing Address - Country:US
Mailing Address - Phone:718-284-0406
Mailing Address - Fax:
Practice Address - Street 1:440 EAST 9TH STREET
Practice Address - Street 2:APT 6 E
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218
Practice Address - Country:US
Practice Address - Phone:718-284-0406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant