Healthcare Provider Details

I. General information

NPI: 1649285230
Provider Name (Legal Business Name): VLADIMIR YEFREMOV PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5637 MARINE PKWY
NEW PORT RICHEY FL
34652-4316
US

IV. Provider business mailing address

2832 RAVENDALE LN
HOLIDAY FL
34691-7837
US

V. Phone/Fax

Practice location:
  • Phone: 727-845-9115
  • Fax: 727-834-5619
Mailing address:
  • Phone: 727-934-4195
  • Fax: 727-507-3618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103553
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103394
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: