Provider Demographics
NPI:1962016360
Name:YASSA PAC LLC
Entity Type:Organization
Organization Name:YASSA PAC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PA-C
Authorized Official - Prefix:
Authorized Official - First Name:MARCOS
Authorized Official - Middle Name:
Authorized Official - Last Name:YASSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-629-7497
Mailing Address - Street 1:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:HAZEL PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48030-0366
Mailing Address - Country:US
Mailing Address - Phone:248-629-7497
Mailing Address - Fax:
Practice Address - Street 1:624 E 9 MILE RD
Practice Address - Street 2:
Practice Address - City:HAZEL PARK
Practice Address - State:MI
Practice Address - Zip Code:48030-1842
Practice Address - Country:US
Practice Address - Phone:248-629-7497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-02
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty