Healthcare Provider Details

I. General information

NPI: 1962016360
Provider Name (Legal Business Name): YASSA PAC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

624 E 9 MILE RD
HAZEL PARK MI
48030-1842
US

IV. Provider business mailing address

PO BOX 366
HAZEL PARK MI
48030-0366
US

V. Phone/Fax

Practice location:
  • Phone: 248-629-7497
  • Fax:
Mailing address:
  • Phone: 248-629-7497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARCOS YASSA
Title or Position: PA-C
Credential:
Phone: 248-629-7497