Provider Demographics
NPI:1841532181
Name:GAPONOV, TANYA (PT)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:GAPONOV
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01854-3500
Mailing Address - Country:US
Mailing Address - Phone:978-459-0546
Mailing Address - Fax:
Practice Address - Street 1:841 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01854-3500
Practice Address - Country:US
Practice Address - Phone:978-459-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2013-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA20338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist