Basic Information
| Provider Information | |||||||||
| NPI: | 1386039220 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETISOV | ||||||||
| FirstName: | JANINE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8633 DEXTER CT | ||||||||
| Address2: | |||||||||
| City: | WOODHAVEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114211028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3474449055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189637272 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2015 | ||||||||
| LastUpdateDate: | 08/26/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 018517 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.