Provider Demographics
NPI:1174645808
Name:IYAMU, VANRIA V
Entity Type:Individual
Prefix:
First Name:VANRIA
Middle Name:V
Last Name:IYAMU
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:VANRIA
Other - Middle Name:
Other - Last Name:IYAMU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:35 MEADOWVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-1322
Mailing Address - Country:US
Mailing Address - Phone:617-506-4471
Mailing Address - Fax:
Practice Address - Street 1:2100 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER CENTER
Practice Address - State:MA
Practice Address - Zip Code:02124-5615
Practice Address - Country:US
Practice Address - Phone:617-506-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAAP1776363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM16011Medicare ID - Type Unspecified