Provider Demographics
NPI:1578251088
Name:YANG, MIA AMAO (CNP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:AMAO
Last Name:YANG
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1073 WATERLOO AVE APT 173C
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-1685
Mailing Address - Country:US
Mailing Address - Phone:612-257-2877
Mailing Address - Fax:
Practice Address - Street 1:2800 CAMPUS DR STE 44
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2669
Practice Address - Country:US
Practice Address - Phone:612-444-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-25
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10109363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily