Provider Demographics
NPI:1316461916
Name:MASHKABOVA, ANGELLA I (PA)
Entity type:Individual
Prefix:
First Name:ANGELLA
Middle Name:I
Last Name:MASHKABOVA
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 1:6334 BOOTH ST
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2032
Mailing Address - Country:US
Mailing Address - Phone:917-340-7846
Mailing Address - Fax:
Practice Address - Street 1:1985 MARCUS AVE # 100
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-2008
Practice Address - Country:US
Practice Address - Phone:855-201-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-26
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019925-1207RE0101X
NY019925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty