Basic Information
| Provider Information | |||||||||
| NPI: | 1760849921 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | YACOVONE | ||||||||
| FirstName: | MARC | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25 TOWN CMN | ||||||||
| Address2: | |||||||||
| City: | GORHAM | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040382671 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 133 BROOKLINE AVE | ||||||||
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| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022153904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6174211000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2016 | ||||||||
| LastUpdateDate: | 10/28/2019 | ||||||||
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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 | 390200000X | RN67056 | ME | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | RN2265881 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.