Provider Demographics
NPI:1457968182
Name:PASTUKH, VYACHESLAV (APN)
Entity Type:Individual
Prefix:
First Name:VYACHESLAV
Middle Name:
Last Name:PASTUKH
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1882 WYNNEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-6771
Mailing Address - Country:US
Mailing Address - Phone:856-777-3968
Mailing Address - Fax:
Practice Address - Street 1:1100 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5002
Practice Address - Country:US
Practice Address - Phone:856-696-0108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01055900363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology