Provider Demographics
NPI:1588022305
Name:SUSHCHAK, TETYANA (PA)
Entity Type:Individual
Prefix:
First Name:TETYANA
Middle Name:
Last Name:SUSHCHAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:290 S WELLWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-4903
Mailing Address - Country:US
Mailing Address - Phone:631-225-2999
Mailing Address - Fax:
Practice Address - Street 1:290 S WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-4903
Practice Address - Country:US
Practice Address - Phone:631-225-2999
Practice Address - Fax:631-225-2104
Is Sole Proprietor?:No
Enumeration Date:2016-02-08
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019412-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant