Basic Information
| Provider Information | |||||||||
| NPI: | 1457611907 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARINOV | ||||||||
| FirstName: | CONSTANTINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MARINOV | ||||||||
| OtherFirstName: | KOSTYANTYN | ||||||||
| OtherMiddleName: | DMYTROVYCH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13805 PEMBROKE LN | ||||||||
| Address2: | |||||||||
| City: | LEAWOOD | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662244506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132712231 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2301 HOLMES ST | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641082640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8164041127 | ||||||||
| FaxNumber: | 8164041103 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2012 | ||||||||
| LastUpdateDate: | 11/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 2007001403 | MO | N | Nursing Service Providers | Registered Nurse | 367500000X | 2012016830 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 919848408 | 05 | MO | MEDICAID |