Basic Information
| Provider Information | |||||||||
| NPI: | 1972661874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASILIEV | ||||||||
| FirstName: | NINA | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400 DATA DR | ||||||||
| Address2: | PHYSICIAN SUPPORT SERVICES | ||||||||
| City: | RANCHO CORDOVA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956707956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9163792948 | ||||||||
| FaxNumber: | 9168587065 | ||||||||
| Practice Location | |||||||||
| Address1: | 1561 CREEKSIDE DRIVE | ||||||||
| Address2: | SUITE 170 | ||||||||
| City: | FOLSOM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169835557 | ||||||||
| FaxNumber: | 9169837878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 01/02/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 13353 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA13353 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207VX0201X | PA13353 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology |
ID Information
| ID | Type | State | Issuer | Description | MV1378644 | 01 | DEA | OTHER |