Provider Demographics
NPI:1942429998
Name:GUSENKOV, MARIYA L (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARIYA
Middle Name:L
Last Name:GUSENKOV
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:34509 9TH AVE S
Mailing Address - Street 2:SUITE 306
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6700
Mailing Address - Country:US
Mailing Address - Phone:253-838-1520
Mailing Address - Fax:253-838-4933
Practice Address - Street 1:34509 9TH AVE S
Practice Address - Street 2:SUITE 306
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6700
Practice Address - Country:US
Practice Address - Phone:253-838-1520
Practice Address - Fax:253-838-4933
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2159GUOtherREGENCE BLUE SHIELD
WA9636481Medicaid