Basic Information
| Provider Information | |||||||||
| NPI: | 1578022448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ILIASHENKO | ||||||||
| FirstName: | TANIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2195 HARRODSBURG RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043504 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2195 HARRODSBURG RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405043504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8593236712 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 09/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | R4988 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 57302 | KY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100680930 | 05 | KY | MEDICAID |