Healthcare Provider Details

I. General information

NPI: 1952359820
Provider Name (Legal Business Name): PETER YEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 05/06/2022
Certification Date: 05/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3675 J DEWEY GRAY CIR STE 300
AUGUSTA GA
30909
US

IV. Provider business mailing address

PO BOX 3726
AUGUSTA GA
30914-3726
US

V. Phone/Fax

Practice location:
  • Phone: 706-863-9595
  • Fax: 706-868-8375
Mailing address:
  • Phone: 706-863-9595
  • Fax: 706-868-8375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9112748
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2204
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.768
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number311887
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-09949
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022719-01
License Number StateNY
# 7
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA0000004411
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA03200
License Number StateTX
# 9
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007148
License Number StateVA
# 10
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9576
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: