Provider Demographics
NPI:1710476155
Name:KOSTYURENKO, VLADIMIR
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:KOSTYURENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11001 EXECUTIVE CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-4393
Mailing Address - Country:US
Mailing Address - Phone:501-812-7215
Mailing Address - Fax:501-812-7207
Practice Address - Street 1:1800 BYPASS ROAD
Practice Address - Street 2:
Practice Address - City:HEBER SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72543-9135
Practice Address - Country:US
Practice Address - Phone:501-202-2093
Practice Address - Fax:501-202-6316
Is Sole Proprietor?:No
Enumeration Date:2018-05-01
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC003256367500000X
WAAP61231826367500000X
FLAPRN11019502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered