Provider Demographics
NPI:1699964262
Name:AVDASHENKO, ALEXANDER (PA-C)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:
Last Name:AVDASHENKO
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 BENSON AVE APT 3G
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11214-4826
Mailing Address - Country:US
Mailing Address - Phone:917-541-5378
Mailing Address - Fax:
Practice Address - Street 1:100 EAST 77TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1883
Practice Address - Country:US
Practice Address - Phone:917-541-5378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012117363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant