Healthcare Provider Details

I. General information

NPI: 1285161604
Provider Name (Legal Business Name): FAFA TSIKATA ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2017
Last Update Date: 05/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 ORCHARD AVE
YEADON PA
19050-3114
US

IV. Provider business mailing address

113 N FRONT ST
LEWISBURG PA
17837-1507
US

V. Phone/Fax

Practice location:
  • Phone: 484-343-0260
  • Fax:
Mailing address:
  • Phone: 484-343-0260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberRT005186
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: