Healthcare Provider Details

I. General information

NPI: 1972889285
Provider Name (Legal Business Name): KSENIYA SHVACHKO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 07/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

837 5TH ST FL 2
SANTA ROSA CA
95404-4526
US

IV. Provider business mailing address

837 5TH ST FL 2
SANTA ROSA CA
95404-4526
US

V. Phone/Fax

Practice location:
  • Phone: 707-522-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA118172
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA118172
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: