Provider Demographics
NPI:1700948924
Name:MEDOCK, YVONNE CARLO (NP)
Entity Type:Individual
Prefix:MS
First Name:YVONNE
Middle Name:CARLO
Last Name:MEDOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 OCEANGATE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4317
Mailing Address - Country:US
Mailing Address - Phone:562-499-6191
Mailing Address - Fax:909-882-8819
Practice Address - Street 1:190 E. HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3658
Practice Address - Country:US
Practice Address - Phone:909-882-4788
Practice Address - Fax:909-882-8819
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006841363L00000X
CA11606363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01805640-DU5182OtherRAILROAD MEDICARE
CA07252016OtherMEDICAL COLTON EFF 7/25/16
CAP01288547/DU4034OtherRAILROAD MEDICARE-SAN BERNARDINO
CAEFF:2/21/13-FONTANAMedicaid
CAEFF.4/23/13-S.RIVERSMedicaid
CAEFF:2/21/13 SAN BERNMedicaid
CAEFF:2/21/13 SAN BERNMedicaid
CAGZ016Z-EFF 1/28/13Medicare PIN