Provider Demographics
NPI:1831305606
Name:LYSSAK, VASSILI FEDOROVICH (PHD)
Entity Type:Individual
Prefix:DR
First Name:VASSILI
Middle Name:FEDOROVICH
Last Name:LYSSAK
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 E 32ND AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-3996
Mailing Address - Country:US
Mailing Address - Phone:509-533-1074
Mailing Address - Fax:509-535-5782
Practice Address - Street 1:2816 E 30TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99223-4782
Practice Address - Country:US
Practice Address - Phone:509-535-1219
Practice Address - Fax:509-535-5782
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00007732225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA107210OtherLABOR & INDUSTRIES IN.