Provider Demographics
NPI:1609043835
Name:SHERESHEVSKY, TATYANA
Entity type:Individual
Prefix:
First Name:TATYANA
Middle Name:
Last Name:SHERESHEVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2205 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2437
Mailing Address - Country:US
Mailing Address - Phone:509-469-6305
Mailing Address - Fax:509-575-3398
Practice Address - Street 1:2205 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2437
Practice Address - Country:US
Practice Address - Phone:509-469-6305
Practice Address - Fax:509-575-3395
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI51975-20207V00000X
CAC136085207VG0400X, 207VX0000X
WAMD61116194207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609043835Medicaid
CA058957Medicaid
CA1609043835Medicaid