Provider Demographics
NPI:1174992184
Name:KOULIKOVA, TETYANA (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:TETYANA
Middle Name:
Last Name:KOULIKOVA
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2272 63RD ST APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-3153
Mailing Address - Country:US
Mailing Address - Phone:929-441-0536
Mailing Address - Fax:
Practice Address - Street 1:2272 63RD ST APT 2F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3153
Practice Address - Country:US
Practice Address - Phone:929-441-0536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-20
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019051207RH0003X, 208800000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No208800000XAllopathic & Osteopathic PhysiciansUrology