Provider Demographics
NPI:1518252709
Name:YANCOVICH, STEPHEN WAYNE JR (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WAYNE
Last Name:YANCOVICH
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:SUITE 510
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:4228 HOUMA BLVD
Practice Address - Street 2:SUITE 510
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-3000
Practice Address - Country:US
Practice Address - Phone:504-454-0141
Practice Address - Fax:504-885-2465
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPENDING363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5CW06PE87OtherMEDICARE PTAN