Provider Demographics
NPI:1174251318
Name:KHASANOV, RENAT (MSN, PMHNP-BC, RN)
Entity type:Individual
Prefix:
First Name:RENAT
Middle Name:
Last Name:KHASANOV
Suffix:
Gender:M
Credentials:MSN, PMHNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2266 BATH AVE # 3010
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-5714
Mailing Address - Country:US
Mailing Address - Phone:917-969-6012
Mailing Address - Fax:
Practice Address - Street 1:75-59 263RD STREET
Practice Address - Street 2:
Practice Address - City:GLEN OAKS
Practice Address - State:NY
Practice Address - Zip Code:11004-1100
Practice Address - Country:US
Practice Address - Phone:718-470-5750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-14
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY404349363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty