MEDICARE: VITALIY VIKTOR KOSTYUKEVICH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA22576	CA

General Provider Information

NPI Number	:	1376881227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VITALIY VIKTOR KOSTYUKEVICH PA-C

Provider Business Mailing Address
First Line	:	4112 E COMMERCE WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-9680
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4112 E COMMERCE WAY
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95834-9680
Country	:	US
Telephone Number	:	916-396-2929
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/28/2013
Last Update Date	:	01/03/2022

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Directions to “ VITALIY VIKTOR KOSTYUKEVICH PA-C” Practice Location

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