Provider Demographics
NPI:1851875066
Name:YANG, JESSICA MIAO (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MIAO
Last Name:YANG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MIAO
Other - Middle Name:
Other - Last Name:YANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:1600 N SYCAMORE AVE APT 401
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-8896
Mailing Address - Country:US
Mailing Address - Phone:843-327-4211
Mailing Address - Fax:
Practice Address - Street 1:405 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-622-8170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN657154163W00000X, 367500000X
MDR210427367500000X
NM60542367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse