Provider Demographics
NPI:1003474198
Name:YECKLEY, SEAN
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:YECKLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 KINGS HWY S
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-5504
Mailing Address - Country:US
Mailing Address - Phone:585-344-5470
Mailing Address - Fax:585-344-7451
Practice Address - Street 1:620 HOWARD AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4804
Practice Address - Country:US
Practice Address - Phone:814-889-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA060685363AS0400X
NY026470363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical