Provider Demographics
NPI:1700182672
Name:POUZAKOV, ALEXEI IVANOVICH (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXEI
Middle Name:IVANOVICH
Last Name:POUZAKOV
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4910 E CLINTON WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1560
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:559-443-2681
Practice Address - Street 1:2823 FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93721-1324
Practice Address - Country:US
Practice Address - Phone:559-459-3770
Practice Address - Fax:559-459-3719
Is Sole Proprietor?:No
Enumeration Date:2011-02-09
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21289363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant