Provider Demographics
NPI:1821061680
Name:POPOVA, YELENA M (PAC)
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:M
Last Name:POPOVA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:877-860-2703
Practice Address - Street 1:3234 MARYSVILLE BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95815-1411
Practice Address - Country:US
Practice Address - Phone:916-646-1200
Practice Address - Fax:877-860-2703
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18255207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEFF: 1/31/12Medicaid
CAMACK RD-EFF 9/27/13Medicaid
CAP01453321-DV5277OtherRAILROAD MEDICARE
CAEFF: 2/20/13Medicaid
CAEFF: 2/20/2013Medicaid
CAP01284219/DS9933OtherRAILROAD MEDICARE
CAPA18255Medicaid
CAGB232A- EFF 3/10/12Medicare PIN
CAPA18255Medicaid
CAEFF: 2/20/13Medicaid
CAMACK RD-EFF 9/27/13Medicaid
CAEFF: 1/31/12Medicaid
CACA142326Medicare PIN
CADR578WMedicare PIN