Provider Demographics
NPI:1689706525
Name:ZINKOVSKY, STANISLAV (OTR, PA-C)
Entity Type:Individual
Prefix:
First Name:STANISLAV
Middle Name:
Last Name:ZINKOVSKY
Suffix:
Gender:M
Credentials:OTR, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5305 LANGLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-2021
Mailing Address - Country:US
Mailing Address - Phone:248-819-0470
Mailing Address - Fax:
Practice Address - Street 1:22972 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4408
Practice Address - Country:US
Practice Address - Phone:248-353-0079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI520106097225X00000X
MI5601005165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI670H202270OtherBCBS
MI670H202270OtherBCBS