Provider Demographics
NPI:1891681698
Name:MIRZAKANOV, SHOSHANA
Entity type:Individual
Prefix:
First Name:SHOSHANA
Middle Name:
Last Name:MIRZAKANOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9928 63RD AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-2117
Mailing Address - Country:US
Mailing Address - Phone:347-527-3967
Mailing Address - Fax:
Practice Address - Street 1:9928 63RD AVE APT 3
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2117
Practice Address - Country:US
Practice Address - Phone:347-527-3967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2598661174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist