Provider Demographics
NPI:1366786204
Name:IGNATOV, IGNAT IVANOV (CSA)
Entity type:Individual
Prefix:
First Name:IGNAT
Middle Name:IVANOV
Last Name:IGNATOV
Suffix:
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13832 W GELDING DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-8352
Mailing Address - Country:US
Mailing Address - Phone:602-451-7496
Mailing Address - Fax:
Practice Address - Street 1:13832 W GELDING DR
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-8352
Practice Address - Country:US
Practice Address - Phone:602-451-7496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4024363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical