Provider Demographics
NPI:1972912178
Name:TSIPORENKO, ALEXANDER (PTA)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:TSIPORENKO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9118 HARRODSBURG RD
Mailing Address - Street 2:
Mailing Address - City:WILMORE
Mailing Address - State:KY
Mailing Address - Zip Code:40390-9752
Mailing Address - Country:US
Mailing Address - Phone:859-858-3831
Mailing Address - Fax:
Practice Address - Street 1:9118 HARRODSBURG RD
Practice Address - Street 2:
Practice Address - City:WILMORE
Practice Address - State:KY
Practice Address - Zip Code:40390-9752
Practice Address - Country:US
Practice Address - Phone:859-858-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-13
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYA02588225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant