MEDICARE: TATYANA VALERIE BURLAKOVA

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	225200000X	Physical Therapy Assistant	A1267	MN

General Provider Information

NPI Number	:	1649976515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TATYANA VALERIE BURLAKOVA

Provider Business Mailing Address
First Line	:	3036 W LAKE ST UNIT 217
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-5236
Country	:	US
Telephone Number	:	612-423-1030
Fax Number	:

Provider Business Practice Location Address
First Line	:	7500 W 22ND ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55426-2602
Country	:	US
Telephone Number	:	763-213-4488
Fax Number	:

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

Provider Enumeration Date	:	02/02/2023
Last Update Date	:	02/02/2023

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