Provider Demographics
NPI:1346435740
Name:SHATSKIKH, KONSTANTIN V (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KONSTANTIN
Middle Name:V
Last Name:SHATSKIKH
Suffix:
Gender:M
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 1:2200 NW 26TH ST
Mailing Address - Street 2:
Mailing Address - City:OWATONNA
Mailing Address - State:MN
Mailing Address - Zip Code:55060-5503
Mailing Address - Country:US
Mailing Address - Phone:504-451-1120
Mailing Address - Fax:
Practice Address - Street 1:2200 NW 26TH ST
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060
Practice Address - Country:US
Practice Address - Phone:504-451-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-09
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant