Provider Demographics
NPI: | 1760693444 |
---|---|
Name: | TSIRULNIKOV, YURI (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | YURI |
Middle Name: | |
Last Name: | TSIRULNIKOV |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1400 E. KINCAID STREET |
Mailing Address - Street 2: | ATTN: CREDENTIALING |
Mailing Address - City: | MOUNT VERNON |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98274-4127 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-428-2500 |
Mailing Address - Fax: | 360-428-6485 |
Practice Address - Street 1: | 1400 E KINCAID ST |
Practice Address - Street 2: | |
Practice Address - City: | MOUNT VERNON |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98274-4127 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-814-6880 |
Practice Address - Fax: | 360-814-6885 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-05-24 |
Last Update Date: | 2018-03-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | 60203919 | 207L00000X, 207LP2900X |
MO | 2008010728 | 207L00000X, 207LP2900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
No | 207L00000X | Allopathic & Osteopathic Physicians | Anesthesiology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MO | 2008010728 | Other | MO LICENSE |