Provider Demographics
NPI:1902537210
Name:GORDYNSKIY-AGEYEV, CHRISTINE LUDA (PAC)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LUDA
Last Name:GORDYNSKIY-AGEYEV
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1078 WHITE HORSE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08610-1425
Mailing Address - Country:US
Mailing Address - Phone:609-581-9100
Mailing Address - Fax:
Practice Address - Street 1:1 CAPITAL WAY
Practice Address - Street 2:
Practice Address - City:PENNINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08534-2520
Practice Address - Country:US
Practice Address - Phone:609-303-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-19
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA063604363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant