Provider Demographics
NPI:1194229765
Name:ZADERETSKII, ROKSOLANA (PA)
Entity type:Individual
Prefix:
First Name:ROKSOLANA
Middle Name:
Last Name:ZADERETSKII
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23451 MADISON ST # 340&300
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4763
Mailing Address - Country:US
Mailing Address - Phone:310-373-6864
Mailing Address - Fax:310-373-3065
Practice Address - Street 1:23451 MADISON ST STE 340&300
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4763
Practice Address - Country:US
Practice Address - Phone:310-373-6864
Practice Address - Fax:310-373-3065
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006520363AS0400X
CAPA62494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical