=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639391089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LYUDMYLA LYSENKO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 04/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 WALLACE BLVD
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-451-4208
-----------------------------------------------------
Fax | 817-563-3699
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6300 RIDGLEA PL SUITE 201
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76116-5704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-451-4208
-----------------------------------------------------
Fax | 817-563-3699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MT189495
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------