Provider Demographics
NPI:1811296197
Name:KAZAKOVA, ELENA (PA-C)
Entity type:Individual
Prefix:
First Name:ELENA
Middle Name:
Last Name:KAZAKOVA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELENA
Other - Middle Name:
Other - Last Name:KAZAKOVA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1945 S OCEAN DR APT 214
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-6077
Mailing Address - Country:US
Mailing Address - Phone:305-331-6128
Mailing Address - Fax:
Practice Address - Street 1:1945 S OCEAN DR APT 214
Practice Address - Street 2:
Practice Address - City:HALLANDALE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33009-6077
Practice Address - Country:US
Practice Address - Phone:305-331-6128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9105687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant