Provider Demographics
NPI:1306900816
Name:MOUSASTICOSHVILY, ANDREI (ND MSC LAC)
Entity type:Individual
Prefix:DR
First Name:ANDREI
Middle Name:
Last Name:MOUSASTICOSHVILY
Suffix:
Gender:M
Credentials:ND MSC LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4320 196TH ST SW STE B
Mailing Address - Street 2:PMB 421
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6754
Mailing Address - Country:US
Mailing Address - Phone:425-876-1094
Mailing Address - Fax:
Practice Address - Street 1:13112 NE 70TH PL
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98033-8571
Practice Address - Country:US
Practice Address - Phone:425-828-7288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1165175F00000X
WAAC00003026171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
No171100000XOther Service ProvidersAcupuncturist