Provider Demographics
NPI:1215423363
Name:PEYSAKHOVICH, ANYA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANYA
Middle Name:
Last Name:PEYSAKHOVICH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:ANYA
Other - Middle Name:
Other - Last Name:PANYUSHENKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:21 TAMAL VISTA BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1133
Mailing Address - Country:US
Mailing Address - Phone:415-927-7660
Mailing Address - Fax:415-927-7663
Practice Address - Street 1:21 TAMAL VISTA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1133
Practice Address - Country:US
Practice Address - Phone:415-927-7660
Practice Address - Fax:415-927-7663
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58169363AS0400X
NY022137363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical