Provider Demographics
NPI:1548325400
Name:PATIN, YURY II
Entity type:Individual
Prefix:
First Name:YURY
Middle Name:
Last Name:PATIN
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 HYLAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1923
Mailing Address - Country:US
Mailing Address - Phone:718-980-6868
Mailing Address - Fax:718-351-0579
Practice Address - Street 1:1432 HYLAN BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1923
Practice Address - Country:US
Practice Address - Phone:718-980-6868
Practice Address - Fax:718-351-0579
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204599174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWAA681Medicare ID - Type Unspecified
NYG36673Medicare UPIN