| Doctor Name: | GENNADIY SHAMALOV |
| NPI Number: | 1174670319 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA |
| License Number: | 008219-1 |
| Business Practice Address: | 141-23 Hoover Ave Briarwood, NY - 114351604 |
| Business Phone Number: | 9177094733 |
| Business Fax Number: | |
| Mailing Address: | 141-23 Hoover Ave, BRIARWOOD |
| State: | NY |
| Postal Code: | 114352930 |
| Phone Number: | 9177094733 |
| Fax Number: | 7185594895 |
| NPI Enumeration Date: | 01/03/2007 |
| NPI Last Update Date: | 09/25/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AS0400X |
| License Number: | 008219-1 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NY |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Surgical |
| Taxonomy Definition: | |