Healthcare Provider Details

I. General information

NPI: 1518252709
Provider Name (Legal Business Name): STEPHEN WAYNE YANCOVICH JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2011
Last Update Date: 06/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4228 HOUMA BLVD SUITE 510
METAIRIE LA
70006-3000
US

IV. Provider business mailing address

1514 JEFFERSON HWY SUITE 510
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-454-0141
  • Fax: 504-885-2465
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPENDING
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: