Provider Demographics
NPI:1205306545
Name:SELYUKOV, VADIM
Entity type:Individual
Prefix:
First Name:VADIM
Middle Name:
Last Name:SELYUKOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 LITTLE LN
Mailing Address - Street 2:
Mailing Address - City:WARMINSTER
Mailing Address - State:PA
Mailing Address - Zip Code:18974-1963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8815 GERMANTOWN AVE STE 16
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2722
Practice Address - Country:US
Practice Address - Phone:215-242-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP019675363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care