1497340582 NPI number — PAVEL VIKTOROVICH SHISHLO APRN FNP-C

Table of content: PAVEL VIKTOROVICH SHISHLO APRN FNP-C (NPI 1497340582)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497340582 NPI number — PAVEL VIKTOROVICH SHISHLO APRN FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHISHLO
Provider First Name:
PAVEL
Provider Middle Name:
VIKTOROVICH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN FNP-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497340582
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6292 ALKIRE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLOWAY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43119-9568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 HOSPITAL DR STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATHENS
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45701-2859
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
403-317-2017
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APRN.CNP.0027952 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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