Provider Demographics
NPI:1053943282
Name:EVDOKIMOVA, LIUDMILA
Entity type:Individual
Prefix:
First Name:LIUDMILA
Middle Name:
Last Name:EVDOKIMOVA
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 1:3836 QUAKERBRIDGE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08619-1006
Mailing Address - Country:US
Mailing Address - Phone:609-246-3864
Mailing Address - Fax:
Practice Address - Street 1:3836 QUAKERBRIDGE RD STE 206
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08619-1006
Practice Address - Country:US
Practice Address - Phone:609-246-3864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00557300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant