Provider Demographics
NPI:1588860209
Name:MISYULYA, TATYANA (MD)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:MISYULYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 TRENTON AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-1613
Mailing Address - Country:US
Mailing Address - Phone:315-797-5810
Mailing Address - Fax:315-732-7030
Practice Address - Street 1:417 TRENTON AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-1613
Practice Address - Country:US
Practice Address - Phone:315-797-5810
Practice Address - Fax:315-732-7030
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254974-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine