Basic Information
| Provider Information | |||||||||
| NPI: | 1073893178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODINTSOV | ||||||||
| FirstName: | PAVEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873906 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 FRANKLIN TPKE | ||||||||
| Address2: | |||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074301304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015290033 | ||||||||
| FaxNumber: | 2015295913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2011 | ||||||||
| LastUpdateDate: | 09/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 306748 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LA2200X | 26NJ00337800 | NJ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.