Provider Demographics
NPI:1801184122
Name:YEDVAB, JONATHAN O (NP)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:O
Last Name:YEDVAB
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4727 LITTLE NECK PKWY
Mailing Address - Street 2:APARTMENT 4G
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF305706363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health