Basic Information
| Provider Information | |||||||||
| NPI: | 1700253929 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVSHALUMOV | ||||||||
| FirstName: | IRADA | ||||||||
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| Credential: | N.P.. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2223 85TH ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112143305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186109312 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4802 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112192916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182836000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2015 | ||||||||
| LastUpdateDate: | 08/24/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 545151-1 | NY | N | Nursing Service Providers | Registered Nurse | 363LF0000X | F338935-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.