Provider Demographics
NPI:1770361677
Name:BOLSHAKOVA-MCGEHEE, TATYANA A (PTA)
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:A
Last Name:BOLSHAKOVA-MCGEHEE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8516 TIMBER RUN CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-7318
Mailing Address - Country:US
Mailing Address - Phone:901-734-5270
Mailing Address - Fax:
Practice Address - Street 1:8516 TIMBER RUN CV
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-7318
Practice Address - Country:US
Practice Address - Phone:901-734-5270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPTA0000004387225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant