Provider Demographics
NPI:1790025955
Name:YANICKO, HEATH MATTHEW (DO)
Entity Type:Individual
Prefix:DR
First Name:HEATH
Middle Name:MATTHEW
Last Name:YANICKO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 LECOM PL
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-2571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:814-868-2522
Practice Address - Street 1:965 SHAMROCK LN
Practice Address - Street 2:
Practice Address - City:CORRY
Practice Address - State:PA
Practice Address - Zip Code:16407-9121
Practice Address - Country:US
Practice Address - Phone:814-664-4641
Practice Address - Fax:814-664-7967
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1030614320003Medicaid
PA1030614320003Medicaid