Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | 009720-1 | NY |
NPI | 1225501083 |
---|---|
Provider Name | Yuriy Nektalov |
First Address | New York, NY 10016-6377 |
Second Address | New York, NY 10016-6377 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/01/2019 |
Last Update Date | 04/01/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
009720-1 | (05) | NY |
009720-1 | STATE OF NEW YORK (01) |