MEDICARE: MYKOLA ALEXANDER PRISICHENKO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA64439	CA

General Provider Information

NPI Number	:	1982464624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MYKOLA ALEXANDER PRISICHENKO

Provider Business Mailing Address
First Line	:	25 PACIFICA APT 6408
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92618-3367
Country	:	US
Telephone Number	:	616-581-8989
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 PACIFICA APT 6408
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92618-3367
Country	:	US
Telephone Number	:	616-581-8989
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2024
Last Update Date	:	02/20/2026

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