=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831238997
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER YANDOW PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 06/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 HOSPITAL LN CALAIS REGIONL HOSPITAL
-----------------------------------------------------
City | CALAIS
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04619-1329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-454-7521
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1345 RIVER RD
-----------------------------------------------------
City | CALAIS
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04619-4202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-214-1296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 009902
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA001265
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------