Healthcare Provider Details

I. General information

NPI: 1861993412
Provider Name (Legal Business Name): DMITRIY TRETIAK NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2018
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6047 TAMPA AVE STE 301
TARZANA CA
91356-1182
US

IV. Provider business mailing address

11539 SANTINI LN
PORTER RANCH CA
91326-4421
US

V. Phone/Fax

Practice location:
  • Phone: 888-407-6706
  • Fax:
Mailing address:
  • Phone: 818-636-9344
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95008578
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: