Provider Demographics
NPI:1285161604
Name:TSIKATA, FAFA (ATC)
Entity type:Individual
Prefix:MISS
First Name:FAFA
Middle Name:
Last Name:TSIKATA
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-1507
Mailing Address - Country:US
Mailing Address - Phone:484-343-0260
Mailing Address - Fax:
Practice Address - Street 1:428 ORCHARD AVE
Practice Address - Street 2:
Practice Address - City:YEADON
Practice Address - State:PA
Practice Address - Zip Code:19050-3114
Practice Address - Country:US
Practice Address - Phone:484-343-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-16
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART005186207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
200005221OtherBOARD OF CERTIFICATION
PART005186OtherPENNSYLVANIA BOARD OF MEDICINE