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General NPI Number Information
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NPI Number | 1861248809
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Entity Type | Individual
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Provider Name | PAVEL NYUKEYEV LD
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Gender | Male
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Dates
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Enumeration Date | 04/29/2024
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Last Update Date | 06/20/2024
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Provider Practice Location Address
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Address Line | 3916 MAIN ST # 104
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City | VANCOUVER
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State | WA
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Zip | 98663-1844
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Country | US
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Telephone | 360-524-2004
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Fax |
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Provider Business Mailing Address
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Address Line | 3916 MAIN ST # 104
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City | VANCOUVER
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State | WA
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Zip | 98663-1844
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Country | US
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Telephone | 360-524-2004
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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 | 122400000X
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Taxonomy Name | Denturist
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License Number | DN61173296
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License Number State | WA
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