Healthcare Provider Details

I. General information

NPI: 1487269346
Provider Name (Legal Business Name): TATYANA KOVALEVSKIJ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2020
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 ACACIA AVE
SAN RAFAEL CA
94901-2230
US

IV. Provider business mailing address

604 STONEYFORD DR
DALY CITY CA
94015-3709
US

V. Phone/Fax

Practice location:
  • Phone: 415-457-4440
  • Fax:
Mailing address:
  • Phone: 415-361-1901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60763
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: