Healthcare Provider Details

I. General information

NPI: 1427337385
Provider Name (Legal Business Name): ALEXANDR TARASYUK PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2011
Last Update Date: 09/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

123 SUMMER STREET
WORCESTER MA
01608
US

V. Phone/Fax

Practice location:
  • Phone: 508-363-6363
  • Fax: 508-363-7164
Mailing address:
  • Phone: 508-363-6363
  • Fax: 508-363-7164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA4219
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2785
License Number StateCT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: