Provider Demographics
NPI:1689688947
Name:PERAKROSTAVA, AKSANA A
Entity Type:Individual
Prefix:
First Name:AKSANA
Middle Name:A
Last Name:PERAKROSTAVA
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 1:282 RIDGEWAY PLZ
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3513
Mailing Address - Country:US
Mailing Address - Phone:215-820-8584
Mailing Address - Fax:215-953-9814
Practice Address - Street 1:9150 MARSHALL ST
Practice Address - Street 2:SUITE #7
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-2217
Practice Address - Country:US
Practice Address - Phone:215-677-6194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA5791220001Medicare NSC