Provider Demographics
NPI:1053198556
Name:KOSTYUK, NATALIA (PTA)
Entity type:Individual
Prefix:
First Name:NATALIA
Middle Name:
Last Name:KOSTYUK
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:345 SHARON TOWNSHIP LN APT 530
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5198
Mailing Address - Country:US
Mailing Address - Phone:980-880-0007
Mailing Address - Fax:
Practice Address - Street 1:600 FULLWOOD RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-2659
Practice Address - Country:US
Practice Address - Phone:704-841-4920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA3891225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant