Provider Demographics
NPI:1427689066
Name:YELIZAVETSKIY, ARTEM S
Entity type:Individual
Prefix:
First Name:ARTEM
Middle Name:S
Last Name:YELIZAVETSKIY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 NW FLANDERS ST STE 304
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-5411
Mailing Address - Country:US
Mailing Address - Phone:360-241-6387
Mailing Address - Fax:
Practice Address - Street 1:2250 NW FLANDERS ST STE 304
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-5411
Practice Address - Country:US
Practice Address - Phone:360-241-6387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-02
Last Update Date:2020-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR25528225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist