Provider Demographics
NPI:1396057733
Name:YASH P SANGWAN M D P A
Entity type:Organization
Organization Name:YASH P SANGWAN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:YASH
Authorized Official - Middle Name:PAL
Authorized Official - Last Name:SANGWAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-261-6209
Mailing Address - Street 1:1411 S 14TH ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-3031
Mailing Address - Country:US
Mailing Address - Phone:904-261-6209
Mailing Address - Fax:904-261-0732
Practice Address - Street 1:1411 S 14TH ST
Practice Address - Street 2:STE C
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-3031
Practice Address - Country:US
Practice Address - Phone:904-261-6209
Practice Address - Fax:904-261-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-13
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78773208C00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001122600Medicaid
FLE2938AOtherMEDICARE LEGACY NUMBER
FL001122600Medicaid