MEDICARE: PAVEL MITRYAEV

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT1823	DC

General Provider Information

NPI Number	:	1275957342
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PAVEL MITRYAEV

Provider Business Mailing Address
First Line	:	3259 PROSPECT ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-3215
Country	:	US
Telephone Number	:	410-422-2652
Fax Number	:

Provider Business Practice Location Address
First Line	:	3259 PROSPECT ST NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20007-3215
Country	:	US
Telephone Number	:	410-422-2652
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/10/2014
Last Update Date	:	02/10/2014

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Directions to “ PAVEL MITRYAEV ” Practice Location

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