Provider Demographics
NPI:1689838427
Name:STAFEEVA, KSENIA A (MD)
Entity Type:Individual
Prefix:
First Name:KSENIA
Middle Name:A
Last Name:STAFEEVA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 WELLNESS WAY STE 402
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4145
Mailing Address - Country:US
Mailing Address - Phone:702-485-5000
Mailing Address - Fax:702-485-5001
Practice Address - Street 1:2020 WELLNESS WAY STE 402
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4145
Practice Address - Country:US
Practice Address - Phone:702-485-5000
Practice Address - Fax:702-485-5005
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA121489207W00000X
NV14891207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1689838427Medicaid
CA0A1214890Medicaid
NV1689838427Medicaid