NPIMap

Individual provider Active NPI

Leonid M Potryasov, MA60290799

  • Massage Therapist
  • Vancouver, WA
National Provider Identifier
1043550866
Registry record updated Feb 15, 2013
On this page

Key facts

NPPES NPI Registry
Primary specialty
Massage TherapistTaxonomy code 225700000X
License
602329198 Issued in WA
Practice address
11300 NE Fourth Plain Blvd
Vancouver, WA 98662-5767
Phone
(360) 931-8054
Fax
(360) 882-8088
NPI assigned
Feb 15, 2013
Last updated
Feb 15, 2013By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Feb 15, 2013

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Massage Therapist 225700000X 602329198 WA Primary

Addresses

Primary practice location

11300 NE Fourth Plain Blvd
Vancouver, WA 98662-5767

Mailing address

11300 NE Fourth Plain Blvd
Vancouver, WA 98662-5767
Phone (360) 931-8054

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled

State licenses

LicenseStateTypeSpecialty
602329198WAMDMassage Therapist

Practice roles

OrganizationSpecialtyStatusNew patients
Healing Touch Massage Therapist Past Accepting new patients

Organizations & group practices 1

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1360886400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1360886400000",
    "number": "1043550866",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "11300 NE FOURTH PLAIN BLVD",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986625767",
            "telephone_number": "360-931-8054",
            "fax_number": "360-882-8088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11300 NE FOURTH PLAIN BLVD",
            "city": "VANCOUVER",
            "state": "WA",
            "postal_code": "986625767",
            "telephone_number": "360-931-8054",
            "fax_number": "360-882-8088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "POTRYASOV",
        "first_name": "LEONID",
        "middle_name": "M",
        "name_prefix": "Mr.",
        "credential": "MA60290799",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2013-02-15",
        "last_updated": "2013-02-15",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "225700000X",
            "taxonomy_group": "",
            "desc": "Massage Therapist",
            "state": "WA",
            "license": "602329198",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Vancouver, WA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 15, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.