Provider Demographics
NPI:1194008870
Name:DESNITSKY, GLEB
Entity Type:Individual
Prefix:
First Name:GLEB
Middle Name:
Last Name:DESNITSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20818 59TH PL W
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-7502
Mailing Address - Country:US
Mailing Address - Phone:425-776-3617
Mailing Address - Fax:
Practice Address - Street 1:6226 196TH ST SW STE 2D
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5959
Practice Address - Country:US
Practice Address - Phone:425-286-5614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60230490171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor