Provider Demographics
NPI:1356125421
Name:BOGOSLOV, YANA PETROVNA
Entity type:Individual
Prefix:
First Name:YANA
Middle Name:PETROVNA
Last Name:BOGOSLOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 947381
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30394-7381
Mailing Address - Country:US
Mailing Address - Phone:386-231-4529
Mailing Address - Fax:386-672-9904
Practice Address - Street 1:305 MEMORIAL MEDICAL PKWY STE 308
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-5137
Practice Address - Country:US
Practice Address - Phone:386-231-3600
Practice Address - Fax:386-231-3602
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9118074363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant