Healthcare Provider Details

I. General information

NPI: 1831577303
Provider Name (Legal Business Name): OLEG S YERMAKOV PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2015
Last Update Date: 09/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 MAIN ST 3RD FLOOR, SUITE C&D
SPRINGFIELD MA
01199-1619
US

IV. Provider business mailing address

280 CHESTNUT ST 2ND FLOOR
SPRINGFIELD MA
01199-1619
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-7033
  • Fax: 413-794-7297
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5466
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: