Healthcare Provider Details

I. General information

NPI: 1104781400
Provider Name (Legal Business Name): DEMITRIY NICHOLAS ASTANIN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9618 NE FOURTH PLAIN BLVD
VANCOUVER WA
98662-6107
US

IV. Provider business mailing address

9618 NE FOURTH PLAIN BLVD
VANCOUVER WA
98662-6107
US

V. Phone/Fax

Practice location:
  • Phone: 360-573-1933
  • Fax:
Mailing address:
  • Phone: 360-573-1933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number70068279
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: