Healthcare Provider Details

I. General information

NPI: 1275039950
Provider Name (Legal Business Name): NATALIYA BAHATYREVICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 E HARDING WAY
STOCKTON CA
95204-6101
US

IV. Provider business mailing address

3400 DATA DR ATTENTION TO: CREDENTIALING AND PAYER ENROLLMENT DEPART
RANCHO CORDOVA CA
95670
US

V. Phone/Fax

Practice location:
  • Phone: 209-946-6800
  • Fax: 209-946-6805
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA164345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: