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General NPI Number Information
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NPI Number | 1578248589
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Entity Type | Individual
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Provider Name | ANDREY MAKSIMTSOV PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/19/2023
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Last Update Date | 10/21/2024
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Provider Practice Location Address
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Address Line | 1800 N CALIFORNIA ST
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City | STOCKTON
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State | CA
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Zip | 95204-6019
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Country | US
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Telephone | 209-943-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 6132 PALMAYA LN
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City | ORANGEVALE
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State | CA
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Zip | 95662-5903
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Country | US
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Telephone | 864-999-0209
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 0010-13321
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA64335
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License Number State | CA
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