Provider Demographics
NPI:1255575312
Name:SHESTOPEROVA, LIDIYA (PA)
Entity type:Individual
Prefix:MRS
First Name:LIDIYA
Middle Name:
Last Name:SHESTOPEROVA
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 1:71 CEDARVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-2048
Mailing Address - Country:US
Mailing Address - Phone:347-251-2099
Mailing Address - Fax:
Practice Address - Street 1:71 CEDARVIEW AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-2048
Practice Address - Country:US
Practice Address - Phone:347-251-2099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2009-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant