Provider Demographics
NPI:1699318295
Name:SMIRNOV, SERGEY (NP)
Entity type:Individual
Prefix:
First Name:SERGEY
Middle Name:
Last Name:SMIRNOV
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6629 BROADWAY APT 5C
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-2040
Mailing Address - Country:US
Mailing Address - Phone:646-552-6494
Mailing Address - Fax:
Practice Address - Street 1:255 RIVERTOWN SHOPS DR STE 102-161
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7506
Practice Address - Country:US
Practice Address - Phone:904-377-3154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-26
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345197363LF0000X
FLAPRN11005649363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily