Provider Demographics
NPI:1902375231
Name:GORYACHKOVSKY, ANNA (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:GORYACHKOVSKY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 OCEAN AVE APT 602
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11229-3954
Mailing Address - Country:US
Mailing Address - Phone:917-375-7433
Mailing Address - Fax:
Practice Address - Street 1:2511 OCEAN AVE APT 602
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11229-3954
Practice Address - Country:US
Practice Address - Phone:917-375-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023010363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant