Provider Demographics
NPI:1497740054
Name:PROVATAS, ANASTAS C (MD)
Entity Type:Individual
Prefix:DR
First Name:ANASTAS
Middle Name:C
Last Name:PROVATAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 MAYFAIR AVE
Mailing Address - Street 2:
Mailing Address - City:HIBBING
Mailing Address - State:MN
Mailing Address - Zip Code:55746-2935
Mailing Address - Country:US
Mailing Address - Phone:218-262-3441
Mailing Address - Fax:218-362-6908
Practice Address - Street 1:3605 MAYFAIR AVE
Practice Address - Street 2:
Practice Address - City:HIBBING
Practice Address - State:MN
Practice Address - Zip Code:55746-2935
Practice Address - Country:US
Practice Address - Phone:218-262-3441
Practice Address - Fax:218-362-6908
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500693207RH0003X
MN105335207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCE71031Medicare UPIN