Provider Demographics
NPI:1073522942
Name:GUTSALYUK, IRINA (PA)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:GUTSALYUK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:IRINA
Other - Middle Name:
Other - Last Name:TSUR-TSAR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3931 LOUISANA AVE. S.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426
Mailing Address - Country:US
Mailing Address - Phone:952-993-2079
Mailing Address - Fax:716-887-5045
Practice Address - Street 1:3931 LOUISANA AVE. S.
Practice Address - Street 2:
Practice Address - City:ST. LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:952-993-2079
Practice Address - Fax:716-887-5045
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009810-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical