Provider Demographics
NPI:1518498088
Name:BUKENOVA, LIDIYA
Entity Type:Individual
Prefix:
First Name:LIDIYA
Middle Name:
Last Name:BUKENOVA
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:ABULKHAIRKHAN STREET 58, APARTMENT # 99
Mailing Address - Street 2:
Mailing Address - City:AKTOBE
Mailing Address - State:AKTOBE OBLAST
Mailing Address - Zip Code:030000
Mailing Address - Country:KZ
Mailing Address - Phone:705-476-8205
Mailing Address - Fax:
Practice Address - Street 1:501 MADISON AVE
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-2401
Practice Address - Country:US
Practice Address - Phone:570-343-2383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-25
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471032207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program