Provider Demographics
NPI:1710916846
Name:BAKHTINOVA, TATYANA V (PA)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:V
Last Name:BAKHTINOVA
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 1:17191 BOTHELL WAY NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-5534
Mailing Address - Country:US
Mailing Address - Phone:206-363-8272
Mailing Address - Fax:
Practice Address - Street 1:17191 BOTHELL WAY NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-5534
Practice Address - Country:US
Practice Address - Phone:206-364-8272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAGAB25977OtherMEDICARE GROUP
WA8473597Medicaid
WAQ74626Medicare UPIN
WA8863102Medicare PIN