Provider Demographics
NPI:1174921688
Name:NIAZOVA, IRINA
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:NIAZOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WATER STREET
Mailing Address - Street 2:2ND FLOOR CRED DEPT
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10041-0004
Mailing Address - Country:US
Mailing Address - Phone:646-680-2888
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:9610 METROPOLITAN AVE
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-6625
Practice Address - Country:US
Practice Address - Phone:718-459-0400
Practice Address - Fax:718-670-6479
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307200363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner