Provider Demographics
NPI:1265867774
Name:JAYAWARDHANA, YASO M (NP)
Entity Type:Individual
Prefix:
First Name:YASO
Middle Name:M
Last Name:JAYAWARDHANA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:YASO
Other - Middle Name:M
Other - Last Name:JAYAWARDHANA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-781-6844
Mailing Address - Fax:417-781-5024
Practice Address - Street 1:1020 MCINTOSH CIR
Practice Address - Street 2:SUITE 102
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3642
Practice Address - Country:US
Practice Address - Phone:417-781-6844
Practice Address - Fax:417-781-5024
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013033431363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner