Provider Demographics
NPI:1083011688
Name:PASTUKH, LIDIYA
Entity Type:Individual
Prefix:
First Name:LIDIYA
Middle Name:
Last Name:PASTUKH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 NW FOUST CIRCLE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986
Mailing Address - Country:US
Mailing Address - Phone:917-362-3916
Mailing Address - Fax:
Practice Address - Street 1:5301 S CONGRESS AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIS
Practice Address - State:FL
Practice Address - Zip Code:33462-1149
Practice Address - Country:US
Practice Address - Phone:561-965-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-25
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9327163367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered