Provider Demographics
NPI:1982464624
Name:PRISICHENKO, MYKOLA ALEXANDER
Entity Type:Individual
Prefix:
First Name:MYKOLA
Middle Name:ALEXANDER
Last Name:PRISICHENKO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3369 QUIGGLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9291
Mailing Address - Country:US
Mailing Address - Phone:616-581-8989
Mailing Address - Fax:
Practice Address - Street 1:3369 QUIGGLE AVE SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9291
Practice Address - Country:US
Practice Address - Phone:616-581-8989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant