MEDICARE: MR. YEVGENIY PUSTILNIKOV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	18429	CA
2	364SG0600X	Gerontology Clinical Nurse Specialist	3055	CA

General Provider Information

NPI Number	:	1053561290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. YEVGENIY PUSTILNIKOV

Provider Business Mailing Address
First Line	:	1335 N LA BREA AVE APT 105
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7565
Country	:	US
Telephone Number	:	323-829-9261
Fax Number	:

Provider Business Practice Location Address
First Line	:	1335 N LA BREA AVE
Second Line	:	APT#105
City	:	LOS ANGELES
State	:	CA
Zip	:	90028-7526
Country	:	US
Telephone Number	:	323-829-9261
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2008
Last Update Date	:	09/24/2008

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