Provider Demographics
NPI:1154871259
Name:SUKHAREV, MAKSIM VLADIMIR (AA,LMT)
Entity type:Individual
Prefix:
First Name:MAKSIM
Middle Name:VLADIMIR
Last Name:SUKHAREV
Suffix:
Gender:M
Credentials:AA,LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8757 46TH PL W
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-3403
Mailing Address - Country:US
Mailing Address - Phone:425-563-8965
Mailing Address - Fax:
Practice Address - Street 1:6808 220TH ST SW STE 203
Practice Address - Street 2:
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2187
Practice Address - Country:US
Practice Address - Phone:425-776-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60584369208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation