Provider Demographics
NPI:1164961157
Name:VESSELOVSKAYA, ELIZABETH V (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:V
Last Name:VESSELOVSKAYA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14800 W MOUNTAIN VIEW BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-2700
Mailing Address - Country:US
Mailing Address - Phone:623-584-3376
Mailing Address - Fax:623-584-3375
Practice Address - Street 1:14800 W MOUNTAIN VIEW BLVD STE 160
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-2700
Practice Address - Country:US
Practice Address - Phone:623-584-3376
Practice Address - Fax:623-584-3375
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant