Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 18429 | CA |
NPI | 1053561290 |
---|---|
Provider Name | Mr. Yevgeniy Pustilnikov |
First Address | Los Angeles, CA 90028-7565 |
Second Address | Los Angeles, CA 90028-7526 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/09/2008 |
Last Update Date | 24/09/2008 |