Provider Demographics
NPI:1386646099
Name:SELIVERSTOV, IRINA (NP)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:SELIVERSTOV
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1505
Mailing Address - Country:US
Mailing Address - Phone:781-581-6181
Mailing Address - Fax:781-599-3229
Practice Address - Street 1:34 STATE ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1505
Practice Address - Country:US
Practice Address - Phone:781-581-6181
Practice Address - Fax:781-599-3229
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD218125363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2289Medicare ID - Type Unspecified
MAP02239Medicare UPIN