Basic Information
| Provider Information | |||||||||
| NPI: | 1336679380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NKENG | ||||||||
| FirstName: | YANNICK | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NKENG | ||||||||
| OtherFirstName: | YANNICK | ||||||||
| OtherMiddleName: | NGUASONG | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 43 WHITING HILL RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | BREWER | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044121006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079735000 | ||||||||
| FaxNumber: | 2079735042 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 UNION ST | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044013060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074048100 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1722 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.