Provider Demographics
NPI:1194055491
Name:KHALILOVA, ROZA (R-PAC)
Entity type:Individual
Prefix:
First Name:ROZA
Middle Name:
Last Name:KHALILOVA
Suffix:
Gender:F
Credentials:R-PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11155 77TH AVE
Mailing Address - Street 2:APT# 1J
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7035
Mailing Address - Country:US
Mailing Address - Phone:718-575-8702
Mailing Address - Fax:
Practice Address - Street 1:1220 AVENUE P
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-1009
Practice Address - Country:US
Practice Address - Phone:718-376-1004
Practice Address - Fax:718-376-1150
Is Sole Proprietor?:No
Enumeration Date:2010-01-08
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant