Provider Demographics
NPI:1275957342
Name:MITRYAEV, PAVEL
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:MITRYAEV
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 1:3259 PROSPECT ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20007-3215
Mailing Address - Country:US
Mailing Address - Phone:410-422-2652
Mailing Address - Fax:
Practice Address - Street 1:3259 PROSPECT ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20007-3215
Practice Address - Country:US
Practice Address - Phone:410-422-2652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMT1823225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist