Healthcare Provider Details

I. General information

NPI: 1063813327
Provider Name (Legal Business Name): RAKHAT ASHYMOV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 05/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 CENTRAL AVENUE
DOLORES CO
81323
US

IV. Provider business mailing address

P.O. BOX 908
DOLORES CO
81323
US

V. Phone/Fax

Practice location:
  • Phone: 970-882-7221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004058
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: