Provider Demographics
NPI:1154963387
Name:TKACIK, ANDREW
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:TKACIK
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 1:43091 COLUMBIANA WATERFORD RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-9435
Mailing Address - Country:US
Mailing Address - Phone:724-630-1126
Mailing Address - Fax:
Practice Address - Street 1:134 HOMER AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-1206
Practice Address - Country:US
Practice Address - Phone:607-756-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026835363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant