Provider Demographics
NPI:1952359820
Name:YEN, PETER
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:YEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3726
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-3726
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-868-8375
Practice Address - Street 1:3675 J DEWEY GRAY CIR STE 300
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:706-868-8375
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112748363A00000X
NVPA2204363A00000X
ALPA.768363A00000X
LA311887363A00000X
NC0010-09949363A00000X
NY022719-01363A00000X
TNPA0000004411363A00000X
TXPA03200363A00000X
VA0110007148363A00000X
GA9576363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL131466Medicaid
AL051118766OtherBCBS
MS08838893Medicaid
ALZ21074OtherVIVA
AL051118764OtherBCBS
AL051118767OtherBCBS
AL051118768OtherBCBS
AL131465Medicaid
AL131466Medicaid