Healthcare Provider Details

I. General information

NPI: 1295646297
Provider Name (Legal Business Name): ILYA GLADKOV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1724 SE 30TH PL
RENTON WA
98055-5201
US

IV. Provider business mailing address

1724 SE 30TH PL
RENTON WA
98055-5201
US

V. Phone/Fax

Practice location:
  • Phone: 425-757-7425
  • Fax: 425-572-5169
Mailing address:
  • Phone: 425-757-7425
  • Fax: 425-572-5169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNC60543014
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: