| Doctor Name: | MR. ANDREI VLADIMIROVICH MITSOUROV |
| NPI Number: | 1205104775 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LMP |
| License Number: | MA 60230518 |
| Business Practice Address: | 53387 W Crockett Rd Milton Freewater, OR - 978627941 |
| Business Phone Number: | 5095401665 |
| Business Fax Number: | |
| Mailing Address: | 53387 W Crockett Rd, MILTON FREEWATER |
| State: | OR |
| Postal Code: | 978627941 |
| Phone Number: | 5095401665 |
| Fax Number: | |
| NPI Enumeration Date: | 12/12/2011 |
| NPI Last Update Date: | 12/12/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225700000X |
| License Number: | MA 60230518 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | WA |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Massage Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual trained in the manipulation of tissues (as by rubbing, stroking, kneading, or tapping) with the hand or an instrument for remedial or hygienic purposes. |