Provider Demographics
NPI:1679595334
Name:YANINA ETLIS DO PC
Entity type:Organization
Organization Name:YANINA ETLIS DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:YANINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:646-250-8282
Mailing Address - Street 1:3030 OCEAN AVE
Mailing Address - Street 2:SUITE AA
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-3363
Mailing Address - Country:US
Mailing Address - Phone:646-250-8282
Mailing Address - Fax:
Practice Address - Street 1:3030 OCEAN AVE
Practice Address - Street 2:SUITE AA
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3363
Practice Address - Country:US
Practice Address - Phone:646-250-8282
Practice Address - Fax:718-769-2365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWET601Medicare ID - Type UnspecifiedEMPIRE