Provider Demographics
NPI:1700206307
Name:YANIK, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:YANIK
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 1:645 AMALIA ST NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2434
Mailing Address - Country:US
Mailing Address - Phone:704-295-3255
Mailing Address - Fax:704-295-7791
Practice Address - Street 1:645 AMALIA ST NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2434
Practice Address - Country:US
Practice Address - Phone:704-295-3255
Practice Address - Fax:704-295-7791
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-22
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2020-02127207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program