Healthcare Provider Details

I. General information

NPI: 1801412044
Provider Name (Legal Business Name): PAK LIK PATRICK YUE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

1120 15TH ST
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 404-723-1199
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number25MA11555200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number100032
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: