Healthcare Provider Details

I. General information

NPI: 1306900816
Provider Name (Legal Business Name): ANDREI MOUSASTICOSHVILY ND. MSC. LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2006
Last Update Date: 08/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13112 NE 70TH PL
KIRKLAND WA
98033-8571
US

IV. Provider business mailing address

4320 196TH ST SW STE B PMB 421
LYNNWOOD WA
98036-6754
US

V. Phone/Fax

Practice location:
  • Phone: 425-828-7288
  • Fax:
Mailing address:
  • Phone: 425-876-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC00003026
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number1165
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: