Provider Demographics
NPI:1013168715
Name:YATSUKNENKO, VICTORIA A (PA-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:YATSUKNENKO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:FAULCONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2307 RIVER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-5000
Mailing Address - Country:US
Mailing Address - Phone:502-583-6647
Mailing Address - Fax:502-585-4824
Practice Address - Street 1:2307 RIVER RD STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-5000
Practice Address - Country:US
Practice Address - Phone:502-583-6647
Practice Address - Fax:502-585-4824
Is Sole Proprietor?:No
Enumeration Date:2008-10-01
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AS0400X
KYPA1148363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000588926OtherANTHEM BLUE CROSS AND BLUE SHIELD
C60483OtherCUMBERLAND HEALTHCARE
KY000000588926OtherANTHEM BLUE CROSS AND BLUE SHIELD