Healthcare Provider Details

I. General information

NPI: 1740814078
Provider Name (Legal Business Name): YVONNE WEN GU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2020
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 1ST ST
MINEOLA NY
11501-3957
US

IV. Provider business mailing address

1867 BEDFORD AVE
MERRICK NY
11566-3503
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-2384
  • Fax:
Mailing address:
  • Phone: 917-853-0927
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025110
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: