Basic Information
| Provider Information | |||||||||
| NPI: | 1073522942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUTSALYUK | ||||||||
| FirstName: | IRINA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TSUR-TSAR | ||||||||
| OtherFirstName: | IRINA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3931 LOUISANA AVE. S. | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529932079 | ||||||||
| FaxNumber: | 7168875045 | ||||||||
| Practice Location | |||||||||
| Address1: | 3931 LOUISANA AVE. S. | ||||||||
| Address2: | |||||||||
| City: | ST. LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529932079 | ||||||||
| FaxNumber: | 7168875045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 11/16/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 009810-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.