Provider Demographics
NPI:1710958814
Name:YIP, JACKIE LAI (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:LAI
Last Name:YIP
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:JACKIE
Other - Middle Name:
Other - Last Name:LAI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:11230 GOLD EXPRESS DR
Mailing Address - Street 2:
Mailing Address - City:GOLD RIVER
Mailing Address - State:CA
Mailing Address - Zip Code:95670-4484
Mailing Address - Country:US
Mailing Address - Phone:916-214-8888
Mailing Address - Fax:
Practice Address - Street 1:11986 PERICLES DR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-8078
Practice Address - Country:US
Practice Address - Phone:916-226-6228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-28
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP34003Medicare UPIN