Provider Demographics
NPI:1649934746
Name:GONCHAROVA, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:GONCHAROVA
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 1:4328 CORAN LANE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 RANCHO LANE
Practice Address - Street 2:#25
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106
Practice Address - Country:US
Practice Address - Phone:702-822-2655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider