Provider Demographics
NPI:1093077737
Name:TYSKA-PETTERSEN, ALLISON
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:
Last Name:TYSKA-PETTERSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 GREGORY PL
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2904
Mailing Address - Country:US
Mailing Address - Phone:631-830-7452
Mailing Address - Fax:
Practice Address - Street 1:1 SCOUTING BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2220
Practice Address - Country:US
Practice Address - Phone:631-297-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1751576174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist