Provider Demographics
NPI:1366194227
Name:NAZAREVYCH, DOVILE
Entity type:Individual
Prefix:
First Name:DOVILE
Middle Name:
Last Name:NAZAREVYCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 W MEDICINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55441-4142
Mailing Address - Country:US
Mailing Address - Phone:612-707-1660
Mailing Address - Fax:
Practice Address - Street 1:2205 W MEDICINE LAKE DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-4142
Practice Address - Country:US
Practice Address - Phone:612-707-1660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN24D2245122OtherCMS, CLIA NUMBER