Provider Demographics
NPI:1730774241
Name:TKACIK, ANDREW (PA)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:TKACIK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13333 NORTHWEST FWY STE 540
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77040-6166
Mailing Address - Country:US
Mailing Address - Phone:414-290-8004
Mailing Address - Fax:
Practice Address - Street 1:13333 NORTHWEST FWY STE 540
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77040-6166
Practice Address - Country:US
Practice Address - Phone:424-290-8004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8815363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program