Provider Demographics
NPI:1982771481
Name:IXANOV, RUSTEM (MS,PT)
Entity Type:Individual
Prefix:MR
First Name:RUSTEM
Middle Name:
Last Name:IXANOV
Suffix:
Gender:M
Credentials:MS,PT
Other - Prefix:MR
Other - First Name:ROUSTEM
Other - Middle Name:
Other - Last Name:IXANOV
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3550 ROUND BARN BLVD # 112
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1796
Mailing Address - Country:US
Mailing Address - Phone:707-566-5488
Mailing Address - Fax:
Practice Address - Street 1:3550 ROUND BARN BLVD # 112
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-1796
Practice Address - Country:US
Practice Address - Phone:707-566-5488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 32358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist