Provider Demographics
NPI:1508019555
Name:YESALAVAGE, ALIA ALYN (CRNP)
Entity Type:Individual
Prefix:
First Name:ALIA
Middle Name:ALYN
Last Name:YESALAVAGE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:47 ROCKLEDGE DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1953
Mailing Address - Country:US
Mailing Address - Phone:570-474-2126
Mailing Address - Fax:
Practice Address - Street 1:150 MUNDY ST
Practice Address - Street 2:MAC IV BUILDING
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6830
Practice Address - Country:US
Practice Address - Phone:570-824-0930
Practice Address - Fax:570-824-7755
Is Sole Proprietor?:No
Enumeration Date:2008-11-03
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PASP010019363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA166364J67Medicare PIN