Provider Demographics
NPI:1073903134
Name:AVERBUKH, ANASTASIA A (NP)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:A
Last Name:AVERBUKH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANASTASIA
Other - Middle Name:A
Other - Last Name:SHESTAKOVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:1011 BOWLES AVENUE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-2387
Mailing Address - Country:US
Mailing Address - Phone:314-200-2713
Mailing Address - Fax:314-200-2714
Practice Address - Street 1:1011 BOWLES AVENUE
Practice Address - Street 2:SUITE 121
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-2387
Practice Address - Country:US
Practice Address - Phone:314-200-2713
Practice Address - Fax:314-200-2714
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014031123363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA4832002Medicare PIN