Healthcare Provider Details

I. General information

NPI: 1023268505
Provider Name (Legal Business Name): LISA M. TKACHENKO PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISS M. YINGLING PA-C

II. Dates (important events)

Enumeration Date: 09/22/2008
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 N KROCKS RD
ALLENTOWN PA
18106-9283
US

IV. Provider business mailing address

PO BOX 159
BARRINGTON NJ
08007-0159
US

V. Phone/Fax

Practice location:
  • Phone: 888-982-8594
  • Fax: 888-920-1525
Mailing address:
  • Phone: 484-884-4500
  • Fax: 484-884-0699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA053629
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: