Provider Demographics
NPI:1548954183
Name:AFANASYEV, PAVEL
Entity type:Individual
Prefix:
First Name:PAVEL
Middle Name:
Last Name:AFANASYEV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20607 ROSCOE BLVD UNIT G
Mailing Address - Street 2:
Mailing Address - City:WINNETKA
Mailing Address - State:CA
Mailing Address - Zip Code:91306-1759
Mailing Address - Country:US
Mailing Address - Phone:818-744-2374
Mailing Address - Fax:
Practice Address - Street 1:6265 SEPULVEDA BLVD STE 6
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1123
Practice Address - Country:US
Practice Address - Phone:818-528-4106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49751225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant