Healthcare Provider Details

I. General information

NPI: 1437794781
Provider Name (Legal Business Name): JOHN YACANO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2019
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33-57 HARRISON ST
JOHNSON CITY NY
13790-2107
US

IV. Provider business mailing address

501 S SHARON AMITY RD STE 300
CHARLOTTE NC
28211-0035
US

V. Phone/Fax

Practice location:
  • Phone: 607-763-6412
  • Fax: 607-763-5854
Mailing address:
  • Phone: 704-377-2424
  • Fax: 704-377-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-12535
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: