Provider Demographics
NPI: | 1033443700 |
---|---|
Name: | CAO, YAN |
Entity Type: | Individual |
Prefix: | |
First Name: | YAN |
Middle Name: | |
Last Name: | CAO |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 2323 W FRONT ST |
Mailing Address - Street 2: | |
Mailing Address - City: | TYLER |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75702-7747 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 903-597-1351 |
Mailing Address - Fax: | 903-535-7384 |
Practice Address - Street 1: | 575 W STATE HIGHWAY 243 |
Practice Address - Street 2: | |
Practice Address - City: | CANTON |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75103-2113 |
Practice Address - Country: | US |
Practice Address - Phone: | 903-567-4197 |
Practice Address - Fax: | 903-535-7384 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2009-09-28 |
Last Update Date: | 2022-08-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 859245 | 363L00000X |
WI | 3845-33 | 363L00000X, 363LP0808X |
TX | AP125462 | 363LP0808X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0808X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psychiatric/Mental Health |
No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 333052403 | Medicaid |