Healthcare Provider Details

I. General information

NPI: 1376606541
Provider Name (Legal Business Name): CHRISTIAN SCOTT YACONO MHS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 04/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 KEYSTONE AVE SUITE 200
DREXEL HILL PA
19026-1129
US

IV. Provider business mailing address

207 N BROAD ST 3RD FLR
PHILA PA
19107
US

V. Phone/Fax

Practice location:
  • Phone: 610-259-0240
  • Fax: 610-259-0606
Mailing address:
  • Phone: 215-462-7100
  • Fax: 215-463-3820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA051570
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: