MEDICARE: IRINA GUTSALYUK PA

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	363AS0400X	Surgical Physician Assistant	009810-1	NY
2	363A00000X	Physician Assistant	PA9109303	FL

General Provider Information

NPI Number	:	1073522942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRINA GUTSALYUK PA

Provider Business Mailing Address
First Line	:	PO BOX 20800
Second Line	:
City	:	BELFAST
State	:	ME
Zip	:	04915-4105
Country	:	US
Telephone Number	:	888-402-7256
Fax Number	:	888-902-1099

Provider Business Practice Location Address
First Line	:	370 SOUTHEAST VERANDA FALLS WAY
Second Line	:	SUITE 102
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984
Country	:	US
Telephone Number	:	772-763-1720
Fax Number	:	772-214-3027

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

Provider Enumeration Date	:	08/07/2006
Last Update Date	:	07/03/2025

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