Healthcare Provider Details

I. General information

NPI: 1831305606
Provider Name (Legal Business Name): VASSILI FEDOROVICH LYSSAK PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2816 E 30TH AVE
SPOKANE WA
99223-4782
US

IV. Provider business mailing address

2214 E 32ND AVE
SPOKANE WA
99203-3996
US

V. Phone/Fax

Practice location:
  • Phone: 509-535-1219
  • Fax: 509-535-5782
Mailing address:
  • Phone: 509-533-1074
  • Fax: 509-535-5782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00007732
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: