Healthcare Provider Details

I. General information

NPI: 1003474198
Provider Name (Legal Business Name): SEAN YECKLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2019
Last Update Date: 06/10/2024
Certification Date: 06/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 NORTH ST
BATAVIA NY
14020-1631
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 585-344-5470
  • Fax: 585-344-7451
Mailing address:
  • Phone: 585-344-5470
  • Fax: 585-344-7451

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA060685
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number026470
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: