Provider Demographics
NPI:1245414929
Name:GAVRONSKY, STAS (LIC AC)
Entity Type:Individual
Prefix:
First Name:STAS
Middle Name:
Last Name:GAVRONSKY
Suffix:
Gender:M
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 WAYLAND HILLS RD
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01778-3820
Mailing Address - Country:US
Mailing Address - Phone:617-630-8508
Mailing Address - Fax:
Practice Address - Street 1:23 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:NEWTON CENTRE
Practice Address - State:MA
Practice Address - Zip Code:02459-1836
Practice Address - Country:US
Practice Address - Phone:617-630-8508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA408171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist