Basic Information
| Provider Information | |||||||||
| NPI: | 1669780557 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | IRYNA | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2040 SEAGIRT BLVD APT 6E | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116915932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202615510 | ||||||||
| FaxNumber: | 3038618624 | ||||||||
| Practice Location | |||||||||
| Address1: | 327 BEACH 19TH ST | ||||||||
| Address2: | |||||||||
| City: | FAR ROCKAWAY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 116914423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188697000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 07/13/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 10369 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 96484543 | 05 | CO | MEDICAID |