Healthcare Provider Details

I. General information

NPI: 1467712455
Provider Name (Legal Business Name): TATYANA N KUVSHINIKOV PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TATYANA N BOVKUN PA-C

II. Dates (important events)

Enumeration Date: 05/23/2012
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 N RIDGE RD E STE 700A
ASHTABULA OH
44004-4300
US

IV. Provider business mailing address

814 KEEFUS RD
CONNEAUT OH
44030-9784
US

V. Phone/Fax

Practice location:
  • Phone: 440-484-2130
  • Fax:
Mailing address:
  • Phone: 814-860-6416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA055473
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.006454RX
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA002842
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: