Provider Demographics
NPI:1114378429
Name:SIDOR, TATYANA (ARNP)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:SIDOR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34876
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1876
Mailing Address - Country:US
Mailing Address - Phone:425-656-5412
Mailing Address - Fax:253-395-1983
Practice Address - Street 1:16850 SE 272ND ST
Practice Address - Street 2:STE 100
Practice Address - City:COVINGTON
Practice Address - State:WA
Practice Address - Zip Code:98042-4931
Practice Address - Country:US
Practice Address - Phone:253-395-1971
Practice Address - Fax:253-395-1983
Is Sole Proprietor?:No
Enumeration Date:2016-06-28
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60669349363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner