Individual
GENNADIY SHAMALOV
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
141-23 HOOVER AVE, BRIARWOOD, NY 11435-1604
(917) 709-4733
Mailing address
141-23 HOOVER AVE, BRIARWOOD, NY 11435-2930
(917) 709-4733
(718) 559-4895
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
008219-1
NY
Other
Enumeration date
01/03/2007
Last updated
09/25/2012
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