Healthcare Provider Details

I. General information

NPI: 1184248395
Provider Name (Legal Business Name): ANNA PETROVNA PUZYRKOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2020
Last Update Date: 04/15/2023
Certification Date: 04/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 CLAYTON RD
SAINT LOUIS MO
63117-1811
US

IV. Provider business mailing address

1ST NOVOKUZMINSKAYA STREET 11 APT 18
MOSCOW MOSCOW
109377
RU

V. Phone/Fax

Practice location:
  • Phone: 314-768-8778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC1-0026029
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: