Healthcare Provider Details

I. General information

NPI: 1255531042
Provider Name (Legal Business Name): TATYANA LYTKINA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2007
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF ROUTE N12 AND N7
FORTDEFIANCE AZ
86504
US

IV. Provider business mailing address

PO BOX 589
FORT DEFIANCE AZ
86504-0589
US

V. Phone/Fax

Practice location:
  • Phone: 928-729-8132
  • Fax:
Mailing address:
  • Phone: 727-515-5743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101950
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: