=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316387608
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELZA TYSHKO DPM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2013
-----------------------------------------------------
Last Update Date | 02/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 ROSE AVE
-----------------------------------------------------
City | FEASTERVILLE TREVOSE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19053-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 267-991-6000
-----------------------------------------------------
Fax | 267-352-4032
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 ROSE AVE
-----------------------------------------------------
City | FEASTERVILLE TREVOSE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19053-4324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-355-7555
-----------------------------------------------------
Fax | 267-352-4032
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | SC006504
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------