MEDICARE: BREANNA YAMETRI POORAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

General Provider Information

NPI Number	:	1578495032
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BREANNA YAMETRI POORAN PA-C

Provider Business Mailing Address
First Line	:	6 KILMER CT
Second Line	:
City	:	LEDGEWOOD
State	:	NJ
Zip	:	07852-2303
Country	:	US
Telephone Number	:	973-479-5562
Fax Number	:

Provider Business Practice Location Address
First Line	:	3000 COLISEUM DR
Second Line	:
City	:	HAMPTON
State	:	VA
Zip	:	23666-5957
Country	:	US
Telephone Number	:	973-479-5562
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2026
Last Update Date	:	06/01/2026

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