Provider Demographics
NPI:1538746169
Name:GONTSCHARENKO, WALESKA MIKAR (SA-C)
Entity type:Individual
Prefix:
First Name:WALESKA
Middle Name:MIKAR
Last Name:GONTSCHARENKO
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 RED BLUFF RD APT 2633
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77507-1152
Mailing Address - Country:US
Mailing Address - Phone:917-514-3296
Mailing Address - Fax:
Practice Address - Street 1:8900 RED BLUFF RD APT 2633
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77507-1152
Practice Address - Country:US
Practice Address - Phone:917-514-3296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-28
Last Update Date:2021-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21-113246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant