Provider Demographics
NPI:1730160920
Name:ETLIS, YANINA (DO)
Entity type:Individual
Prefix:
First Name:YANINA
Middle Name:
Last Name:ETLIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9785 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-3319
Mailing Address - Country:US
Mailing Address - Phone:718-261-9100
Mailing Address - Fax:718-261-6483
Practice Address - Street 1:9785 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-3319
Practice Address - Country:US
Practice Address - Phone:718-261-9100
Practice Address - Fax:718-261-6483
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228241207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02462251Medicaid
NY0566P1Medicare ID - Type Unspecified
NY02462251Medicaid