Healthcare Provider Details

I. General information

NPI: 1962349498
Provider Name (Legal Business Name): TATIANA VICTOROVNA ANSIMOVA P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2026
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17720 N BAY RD APT 6A
SUNNY ISLES BEACH FL
33160-2806
US

IV. Provider business mailing address

17720 N BAY RD APT 6A
SUNNY ISLES BEACH FL
33160-2806
US

V. Phone/Fax

Practice location:
  • Phone: 267-916-3989
  • Fax:
Mailing address:
  • Phone: 267-916-3989
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3077
License Number StatePR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3077
License Number StatePR
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3077
License Number StatePR
# 4
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number25-285
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: