Provider Demographics
NPI:1528579950
Name:SHUMKOV, JULIA VLADA (PA)
Entity Type:Individual
Prefix:MS
First Name:JULIA
Middle Name:VLADA
Last Name:SHUMKOV
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:111 E DUNLAP AVE
Mailing Address - Street 2:STE I-279
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-2807
Mailing Address - Country:US
Mailing Address - Phone:480-331-6721
Mailing Address - Fax:602-296-7738
Practice Address - Street 1:3100 PRINCETON PIKE STE D
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2300
Practice Address - Country:US
Practice Address - Phone:844-464-6387
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00450400363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ$$$$$$$$$OtherSOCIAL SECURITY