Provider Demographics
NPI:1487755336
Name:SHALOMOVA, ELINA (PA)
Entity type:Individual
Prefix:
First Name:ELINA
Middle Name:
Last Name:SHALOMOVA
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 1:9810 64TH AVE APT 3H
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2502
Mailing Address - Country:US
Mailing Address - Phone:347-306-5031
Mailing Address - Fax:
Practice Address - Street 1:9810 64TH AVE APT 3H
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2502
Practice Address - Country:US
Practice Address - Phone:917-517-9743
Practice Address - Fax:917-517-9743
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011421363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00246075Medicaid
NY00246075Medicaid