Healthcare Provider Details

I. General information

NPI: 1104143361
Provider Name (Legal Business Name): Y A ANESTHESIA PAIN MANAGEMENT PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2010
Last Update Date: 12/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3930 RICHMOND AVE SUITE 101
STATEN ISLAND NY
10312-5104
US

IV. Provider business mailing address

5 OAKWOOD CT
HOLMDEL NJ
07733-1753
US

V. Phone/Fax

Practice location:
  • Phone: 917-414-0617
  • Fax: 732-847-3062
Mailing address:
  • Phone: 917-414-0617
  • Fax: 732-847-3062

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number209053
License Number StateNY

VIII. Authorized Official

Name: YVETTE R ABRAHAM
Title or Position: OWNER
Credential: M.D.
Phone: 917-414-0617