MEDICARE: KSENIA PETRUSHKINA 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	363A00000X	Physician Assistant	1150989	FL

General Provider Information

NPI Number	:	1972119451
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KSENIA PETRUSHKINA PA

Provider Business Mailing Address
First Line	:	17121 COLLINS AVE APT 1907
Second Line	:
City	:	SUNNY ISLES BEACH
State	:	FL
Zip	:	33160-4380
Country	:	US
Telephone Number	:	786-564-3612
Fax Number	:

Provider Business Practice Location Address
First Line	:	17121 COLLINS AVE APT 1907
Second Line	:
City	:	SUNNY ISLES BEACH
State	:	FL
Zip	:	33160-4380
Country	:	US
Telephone Number	:	786-564-3612
Fax Number	:

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

Provider Enumeration Date	:	09/19/2020
Last Update Date	:	09/19/2020

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Directions to “ KSENIA PETRUSHKINA PA” Practice Location

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