Provider Demographics
NPI:1891003943
Name:DERTLIEVA-POPOVA, ANASTASIA P (PA)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:P
Last Name:DERTLIEVA-POPOVA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34120
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89533-4120
Mailing Address - Country:US
Mailing Address - Phone:775-747-5050
Mailing Address - Fax:
Practice Address - Street 1:2575 E BIDWELL ST
Practice Address - Street 2:SUITE 230
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-6444
Practice Address - Country:US
Practice Address - Phone:916-984-3899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-22
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant