Provider Demographics
NPI:1790749869
Name:YANG, JAE T (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:T
Last Name:YANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:443 BUTLER RD
Mailing Address - Street 2:
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-4409
Mailing Address - Country:US
Mailing Address - Phone:724-548-8121
Mailing Address - Fax:724-548-7239
Practice Address - Street 1:443 BUTLER RD
Practice Address - Street 2:
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-4409
Practice Address - Country:US
Practice Address - Phone:724-548-8121
Practice Address - Fax:724-548-7239
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD032977L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006100910001Medicaid
PAC30285Medicare UPIN
PA106446Medicare ID - Type Unspecified