Provider Demographics
NPI:1356533814
Name:KORSHUN, OLEXIY (ETC)
Entity type:Individual
Prefix:
First Name:OLEXIY
Middle Name:
Last Name:KORSHUN
Suffix:
Gender:M
Credentials:ETC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4375 LAS VEGAS BLVD N
Mailing Address - Street 2:SUITE#6
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89115-0587
Mailing Address - Country:US
Mailing Address - Phone:702-643-2548
Mailing Address - Fax:
Practice Address - Street 1:4375 NORTH LAS VEGAS BLVD.
Practice Address - Street 2:SUITE #6
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89115
Practice Address - Country:US
Practice Address - Phone:702-643-2548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB6443215332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies