Provider Demographics
NPI:1003121203
Name:KUSTOVA, YULIA (PA)
Entity type:Individual
Prefix:MRS
First Name:YULIA
Middle Name:
Last Name:KUSTOVA
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 1:7000 HAWTHORN AVE APT 304
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90028-6963
Mailing Address - Country:US
Mailing Address - Phone:323-350-2220
Mailing Address - Fax:
Practice Address - Street 1:2121 S SAN PEDRO ST STE E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1161
Practice Address - Country:US
Practice Address - Phone:213-742-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20749363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant