Provider Demographics
NPI:1578248589
Name:MAKSIMTSOV, ANDREY (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREY
Middle Name:
Last Name:MAKSIMTSOV
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 1:112 MIDDLEBROOKE LN
Mailing Address - Street 2:
Mailing Address - City:WELLFORD
Mailing Address - State:SC
Mailing Address - Zip Code:29385-8910
Mailing Address - Country:US
Mailing Address - Phone:864-999-0209
Mailing Address - Fax:
Practice Address - Street 1:600 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-6000
Practice Address - Country:US
Practice Address - Phone:980-993-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13321363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical