Provider Demographics
NPI:1659638682
Name:YAGNINIM, FARE KASSAM II (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:FARE
Middle Name:KASSAM
Last Name:YAGNINIM
Suffix:II
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 FRANKLIN AVE APT 2K
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-5575
Mailing Address - Country:US
Mailing Address - Phone:347-948-2761
Mailing Address - Fax:
Practice Address - Street 1:111 EAST 210 ST
Practice Address - Street 2:MONTEFIORE MEDICAL CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467
Practice Address - Country:US
Practice Address - Phone:718-920-4321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015550-1146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant