Provider Demographics
NPI:1164043162
Name:OSIPCHUK, SLAVIK (NP)
Entity Type:Individual
Prefix:
First Name:SLAVIK
Middle Name:
Last Name:OSIPCHUK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:VYACHESLAV
Other - Middle Name:
Other - Last Name:OSIPCHUK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2329 W ROOT CREEK ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4678
Mailing Address - Country:US
Mailing Address - Phone:208-724-4750
Mailing Address - Fax:
Practice Address - Street 1:2329 W ROOT CREEK ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4678
Practice Address - Country:US
Practice Address - Phone:208-724-4750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-30
Last Update Date:2020-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID62202363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner