Healthcare Provider Details

I. General information

NPI: 1033443700
Provider Name (Legal Business Name): YAN CAO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2009
Last Update Date: 08/15/2022
Certification Date: 08/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 W STATE HIGHWAY 243
CANTON TX
75103-2113
US

IV. Provider business mailing address

2323 W FRONT ST
TYLER TX
75702-7747
US

V. Phone/Fax

Practice location:
  • Phone: 903-567-4197
  • Fax: 903-535-7384
Mailing address:
  • Phone: 903-597-1351
  • Fax: 903-535-7384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number859245
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3845-33
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3845-33
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP125462
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: