Healthcare Provider Details

I. General information

NPI: 1013659390
Provider Name (Legal Business Name): GEVORK MKRTCHYAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3732 E THOMAS AVE
FRESNO CA
93702-1241
US

IV. Provider business mailing address

3079 W SAN RAMON AVE
FRESNO CA
93711-2633
US

V. Phone/Fax

Practice location:
  • Phone: 559-558-6268
  • Fax:
Mailing address:
  • Phone: 559-558-6268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: