Healthcare Provider Details

I. General information

NPI: 1154682169
Provider Name (Legal Business Name): YANA PUCKETT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: YANA YEVSTEGNEYEVA

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 DON WICKHAM DR STE 140D
CLERMONT FL
34711-1979
US

IV. Provider business mailing address

1900 DON WICKHAM DR STE 140D
CLERMONT FL
34711-1979
US

V. Phone/Fax

Practice location:
  • Phone: 321-843-8370
  • Fax: 321-843-6886
Mailing address:
  • Phone: 321-843-8370
  • Fax: 321-843-6886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number30616
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBP10043382
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number92536
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License Number30616
License Number StateWV
# 5
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberME169092
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: