Provider Demographics
NPI:1508675216
Name:DZYUBA, IVAN (FNP)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:DZYUBA
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 COYLE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-0400
Mailing Address - Country:US
Mailing Address - Phone:916-330-4447
Mailing Address - Fax:916-414-9054
Practice Address - Street 1:5900 COYLE AVE STE A
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-0400
Practice Address - Country:US
Practice Address - Phone:916-330-4447
Practice Address - Fax:916-414-9054
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032393363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner