Provider Demographics
NPI:1891485900
Name:PUSTOVOY, PAVEL (CEO)
Entity Type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:PUSTOVOY
Suffix:
Gender:M
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7328 THALIA WAY
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95621-5595
Mailing Address - Country:US
Mailing Address - Phone:916-790-0993
Mailing Address - Fax:
Practice Address - Street 1:5753 AUBURN BLVD STE 23
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-2953
Practice Address - Country:US
Practice Address - Phone:916-790-0993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-11
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY4856046343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)