Healthcare Provider Details

I. General information

NPI: 1235955642
Provider Name (Legal Business Name): YASER TAISEER AWAWDEH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2024
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 TIMES SQ
NEW YORK NY
10036-6564
US

IV. Provider business mailing address

61 LANDSCAPE AVE
YONKERS NY
10705-3831
US

V. Phone/Fax

Practice location:
  • Phone: 914-359-8175
  • Fax:
Mailing address:
  • Phone: 914-359-8175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number036403-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: