Provider Demographics
NPI:1407087497
Name:YEN-MANCUSO, SOVONNA S (PA)
Entity Type:Individual
Prefix:
First Name:SOVONNA
Middle Name:S
Last Name:YEN-MANCUSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 MCCLELLAN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12304-1020
Mailing Address - Country:US
Mailing Address - Phone:518-382-2260
Mailing Address - Fax:518-347-5007
Practice Address - Street 1:624 MCCLELLAN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12304-1020
Practice Address - Country:US
Practice Address - Phone:518-382-2260
Practice Address - Fax:518-347-5007
Is Sole Proprietor?:No
Enumeration Date:2009-08-07
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY013379-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant