1043394216 NPI number — LARISA ALEXEYEVNA YARCZOWER PA-C

Table of content: LARISA ALEXEYEVNA YARCZOWER PA-C (NPI 1043394216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043394216 NPI number — LARISA ALEXEYEVNA YARCZOWER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
YARCZOWER
Provider First Name:
LARISA
Provider Middle Name:
ALEXEYEVNA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAVLENKO
Provider Other First Name:
LARISA
Provider Other Middle Name:
ALEXEYEVNA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043394216
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 N ACADEMY AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17822-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-271-6144
Provider Business Mailing Address Fax Number:
570-271-6578

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 E. MOUNTAIN DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILKES-BARRE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-820-6150
Provider Business Practice Location Address Fax Number:
570-342-3316
Provider Enumeration Date:
10/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  MA003388L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 113856300 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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