Provider Demographics
NPI:1093515652
Name:PISARENKO, ROMAN LEONIDOVICH (PTA)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:LEONIDOVICH
Last Name:PISARENKO
Suffix:
Gender:
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 BLISS ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3401
Mailing Address - Country:US
Mailing Address - Phone:413-304-1078
Mailing Address - Fax:
Practice Address - Street 1:81 BLISS ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3401
Practice Address - Country:US
Practice Address - Phone:413-304-1078
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-13
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10005225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant