Provider Demographics
NPI:1447836457
Name:TETELMAN, KONSTANTIN (NP)
Entity type:Individual
Prefix:
First Name:KONSTANTIN
Middle Name:
Last Name:TETELMAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 HERITAGE DR
Mailing Address - Street 2:
Mailing Address - City:JAMISON
Mailing Address - State:PA
Mailing Address - Zip Code:18929-1629
Mailing Address - Country:US
Mailing Address - Phone:267-902-3060
Mailing Address - Fax:
Practice Address - Street 1:7170 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:FORT WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:19034-2301
Practice Address - Country:US
Practice Address - Phone:215-641-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2021-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023490363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health