Provider Demographics
NPI:1831644020
Name:SHOSTAK, ELENA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ELENA
Middle Name:
Last Name:SHOSTAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:ELENI
Other - Middle Name:
Other - Last Name:KREIZIDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6021 LINDLEY AVE UNIT 8
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-1726
Mailing Address - Country:US
Mailing Address - Phone:323-788-8277
Mailing Address - Fax:
Practice Address - Street 1:14600 SHERMAN WAY STE 250
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-2284
Practice Address - Country:US
Practice Address - Phone:818-212-2223
Practice Address - Fax:818-212-2224
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-18
Last Update Date:2016-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53310363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical