Provider Demographics
NPI:1275105819
Name:MIKHAILOUSKI, SIARHEI
Entity Type:Individual
Prefix:
First Name:SIARHEI
Middle Name:
Last Name:MIKHAILOUSKI
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 1:6842 IRISH RD
Mailing Address - Street 2:
Mailing Address - City:MARCY
Mailing Address - State:NY
Mailing Address - Zip Code:13403-2911
Mailing Address - Country:US
Mailing Address - Phone:315-725-4186
Mailing Address - Fax:
Practice Address - Street 1:201 STATE ST ERIE
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16550-0001
Practice Address - Country:US
Practice Address - Phone:315-725-4186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN724693163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PARN724693OtherPA RN LICENSE