Healthcare Provider Details

I. General information

NPI: 1528477023
Provider Name (Legal Business Name): NALY YANG PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2014
Last Update Date: 05/26/2022
Certification Date: 05/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1635 S 21ST ST
MANITOWOC WI
54220-6380
US

IV. Provider business mailing address

500 KIRTS BLVD STE 100
TROY MI
48084-4135
US

V. Phone/Fax

Practice location:
  • Phone: 920-320-6635
  • Fax:
Mailing address:
  • Phone: 248-434-6169
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3305-23
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: