Healthcare Provider Details

I. General information

NPI: 1144864711
Provider Name (Legal Business Name): KA DEY YANG PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2019
Last Update Date: 09/16/2022
Certification Date: 09/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 E BOSTON POST RD STE 201
MAMARONECK NY
10543-3704
US

IV. Provider business mailing address

1150 DESOTO ST
SAINT PAUL MN
55130-3605
US

V. Phone/Fax

Practice location:
  • Phone: 914-834-1777
  • Fax:
Mailing address:
  • Phone: 920-544-1280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13251
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number028626-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: