Provider Demographics
NPI:1831577303
Name:YERMAKOV, OLEG S (PA)
Entity type:Individual
Prefix:
First Name:OLEG
Middle Name:S
Last Name:YERMAKOV
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:280 CHESTNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01199-1619
Mailing Address - Country:US
Mailing Address - Phone:413-794-5700
Mailing Address - Fax:
Practice Address - Street 1:3300 MAIN ST
Practice Address - Street 2:3RD FLOOR, SUITE C&D
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1619
Practice Address - Country:US
Practice Address - Phone:413-794-7033
Practice Address - Fax:413-794-7297
Is Sole Proprietor?:No
Enumeration Date:2015-05-15
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA5466363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical