Provider Demographics
NPI:1255092755
Name:YACAVONIS, TESSA
Entity type:Individual
Prefix:
First Name:TESSA
Middle Name:
Last Name:YACAVONIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3038 STEINWAY ST APT 8
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3802
Mailing Address - Country:US
Mailing Address - Phone:508-801-5963
Mailing Address - Fax:
Practice Address - Street 1:3038 STEINWAY ST APT 8
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3802
Practice Address - Country:US
Practice Address - Phone:508-801-5963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant