Basic Information
| Provider Information | |||||||||
| NPI: | 1003460601 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | TEGENU | ||||||||
| FirstName: | YONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11605 N LAMAR BLVD | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787532658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7372226996 | ||||||||
| FaxNumber: | 5125228836 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 W 57TH ST | ||||||||
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| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100192121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2123368329 | ||||||||
| FaxNumber: | 2122452587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2019 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 156FX1800X | 009269 | NY | Y | Eye and Vision Services Providers | Technician/Technologist | Optician |
No ID Information.