Healthcare Provider Details

I. General information

NPI: 1033908520
Provider Name (Legal Business Name): ELIZABETH YAGAZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2025
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 NEW SCOTLAND AVE
ALBANY NY
12208-3409
US

IV. Provider business mailing address

1201 STONEGATE DR
RENSSELAER NY
12144-8323
US

V. Phone/Fax

Practice location:
  • Phone: 518-549-6000
  • Fax:
Mailing address:
  • Phone: 914-396-0403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number694510
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: