Basic Information
Provider Information | |||||||||
NPI: | 1790025955 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | YANICKO | ||||||||
FirstName: | HEATH | ||||||||
MiddleName: | MATTHEW | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 LECOM PL | ||||||||
Address2: |   | ||||||||
City: | ERIE | ||||||||
State: | PA | ||||||||
PostalCode: | 165052571 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: | 8148682522 | ||||||||
Practice Location | |||||||||
Address1: | 965 SHAMROCK LN | ||||||||
Address2: |   | ||||||||
City: | CORRY | ||||||||
State: | PA | ||||||||
PostalCode: | 164079121 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8146644641 | ||||||||
FaxNumber: | 8146647967 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2013 | ||||||||
LastUpdateDate: | 01/05/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OT014991 | PA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1030614320003 | 05 | PA |   | MEDICAID |