Provider Demographics
NPI:1699276618
Name:PULATOV, OTABEK (PA-C)
Entity type:Individual
Prefix:MR
First Name:OTABEK
Middle Name:
Last Name:PULATOV
Suffix:
Gender:M
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 1:2940 OCEAN PARKWAY
Mailing Address - Street 2:20D
Mailing Address - City:BROOKYLN
Mailing Address - State:NY
Mailing Address - Zip Code:11235
Mailing Address - Country:US
Mailing Address - Phone:347-586-7775
Mailing Address - Fax:
Practice Address - Street 1:3311 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3611
Practice Address - Country:US
Practice Address - Phone:718-667-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1151097OtherNCCPA ID