Provider Demographics
NPI:1124650528
Name:YEPES CORREA, EDGAR ADRIAN
Entity type:Individual
Prefix:
First Name:EDGAR
Middle Name:ADRIAN
Last Name:YEPES CORREA
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 1:1315 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2927
Mailing Address - Country:US
Mailing Address - Phone:510-881-5921
Mailing Address - Fax:510-291-9591
Practice Address - Street 1:2035 FAIRMONT DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1088
Practice Address - Country:US
Practice Address - Phone:866-866-7496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95303748163W00000X
CA95030839363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse