Provider Demographics
NPI:1104366657
Name:MITCHELL, BECKY YEN
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:YEN
Last Name:MITCHELL
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 1:9 N MCCONNELL AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1248
Mailing Address - Country:US
Mailing Address - Phone:408-828-3211
Mailing Address - Fax:
Practice Address - Street 1:1 LAUTERBUR DRIVE
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-3733
Practice Address - Country:US
Practice Address - Phone:408-828-3211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020541-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant