Healthcare Provider Details

I. General information

NPI: 1396057733
Provider Name (Legal Business Name): YASH P SANGWAN M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 S 14TH ST STE C
FERNANDINA BEACH FL
32034-3031
US

IV. Provider business mailing address

1411 S 14TH ST SUITE C
FERNANDINA BEACH FL
32034-3031
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-6209
  • Fax: 904-261-0732
Mailing address:
  • Phone: 904-261-6209
  • Fax: 904-261-0732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberME78773
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License NumberME78773
License Number StateFL

VIII. Authorized Official

Name: DR. YASH PAL SANGWAN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-261-6209