Provider Demographics
NPI:1750860466
Name:PATATANYAN, MKRTICH (DO)
Entity Type:Individual
Prefix:DR
First Name:MKRTICH
Middle Name:
Last Name:PATATANYAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 RIVERBEND DR APT 105
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-4081
Mailing Address - Country:US
Mailing Address - Phone:818-903-3266
Mailing Address - Fax:
Practice Address - Street 1:96 15TH ST NW STE 106
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1625
Practice Address - Country:US
Practice Address - Phone:276-678-3488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-13
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A18882208M00000X
VA0116032277207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0116032277OtherDEPARTMENT OF HEALTH PROFESSIONALS COMMONWEALTH VIRGINIA