Basic Information
| Provider Information | |||||||||
| NPI: | 1619485281 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YAM | ||||||||
| FirstName: | GARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 68 S SERVICE RD STE 350 | ||||||||
| Address2: | |||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117472358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169453156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 COMMUNITY DR DEPT OF | ||||||||
| Address2: | |||||||||
| City: | MANHASSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165624887 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2018 | ||||||||
| LastUpdateDate: | 07/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 652027 | NY | N | Nursing Service Providers | Registered Nurse | 367500000X | 652027 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 652027 | 01 | NY | NYSED NEW YORK STATE EDUCATION DEPARTMENT | OTHER |