Healthcare Provider Details

I. General information

NPI: 1457565947
Provider Name (Legal Business Name): PEDIATRICS OF ST. AUGUSTINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 07/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2676 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6191
US

IV. Provider business mailing address

2676 US HIGHWAY 1 S
ST AUGUSTINE FL
32086-6191
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-2121
  • Fax:
Mailing address:
  • Phone: 904-797-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME87309
License Number StateFL

VIII. Authorized Official

Name: DR. ALIYA M YASIN
Title or Position: PRESIDENT
Credential: MD
Phone: 904-797-2121