Provider Demographics
NPI:1285048876
Name:TARASOVSKIY, KONSTANTIN
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:TARASOVSKIY
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 1:1400 GANDY BLVD N UNIT 516
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-2124
Mailing Address - Country:US
Mailing Address - Phone:813-770-3118
Mailing Address - Fax:
Practice Address - Street 1:1400 GANDY BLVD N UNIT 516
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-2124
Practice Address - Country:US
Practice Address - Phone:813-770-3118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLT621-519-68-378-0343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)