Provider Demographics
NPI:1558149823
Name:MOROZOV, ANASTASY ALEX
Entity Type:Individual
Prefix:
First Name:ANASTASY
Middle Name:ALEX
Last Name:MOROZOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13570 LORENZO BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46074-8282
Mailing Address - Country:US
Mailing Address - Phone:317-514-3776
Mailing Address - Fax:
Practice Address - Street 1:13570 LORENZO BLVD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46074-8282
Practice Address - Country:US
Practice Address - Phone:317-514-3776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-18
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10004175A363A00000X
IN1212253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant