Provider Demographics
NPI:1831406727
Name:FAN, YANLI (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:YANLI
Middle Name:
Last Name:FAN
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1044 BELMONT AVENUE
Mailing Address - Street 2:DEPARTMENT OF MEDICAL EDUCATION
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44501-1006
Mailing Address - Country:US
Mailing Address - Phone:617-223-7806
Mailing Address - Fax:
Practice Address - Street 1:1044 BELMONT AVENUE
Practice Address - Street 2:DEPARTMENT OF MEDICAL EDUCATION
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44501-1006
Practice Address - Country:US
Practice Address - Phone:617-223-7806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254594207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400311063Medicare PIN