Provider Demographics
NPI:1780339424
Name:YEGANEH, GABRIELLA (PA-C)
Entity type:Individual
Prefix:
First Name:GABRIELLA
Middle Name:
Last Name:YEGANEH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 BROOK LN
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-3100
Mailing Address - Country:US
Mailing Address - Phone:516-592-9639
Mailing Address - Fax:
Practice Address - Street 1:9 BROOK LN
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-3100
Practice Address - Country:US
Practice Address - Phone:516-592-9639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026624363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant