Provider Demographics
NPI:1457565947
Name:PEDIATRICS OF ST. AUGUSTINE
Entity Type:Organization
Organization Name:PEDIATRICS OF ST. AUGUSTINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALIYA
Authorized Official - Middle Name:M
Authorized Official - Last Name:YASIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-797-2121
Mailing Address - Street 1:2676 US HIGHWAY 1 S
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-6191
Mailing Address - Country:US
Mailing Address - Phone:904-797-2121
Mailing Address - Fax:
Practice Address - Street 1:2676 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6191
Practice Address - Country:US
Practice Address - Phone:904-797-2121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME87309208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty