Provider Demographics
NPI:1386367142
Name:ILYASOV, NIKOL (PA-C)
Entity type:Individual
Prefix:
First Name:NIKOL
Middle Name:
Last Name:ILYASOV
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 NORTHERN BOULVARD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:GREENVALE
Mailing Address - State:NY
Mailing Address - Zip Code:11548
Mailing Address - Country:US
Mailing Address - Phone:877-896-9301
Mailing Address - Fax:
Practice Address - Street 1:2200 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:GREENVALE
Practice Address - State:NY
Practice Address - Zip Code:11548-1219
Practice Address - Country:US
Practice Address - Phone:877-896-9301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant