Basic Information
| Provider Information | |||||||||
| NPI: | 1801157151 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YAZBAK TOUSSAINT | ||||||||
| FirstName: | KACIA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9484 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029409484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542500 | ||||||||
| FaxNumber: | 4018542519 | ||||||||
| Practice Location | |||||||||
| Address1: | 164 SUMMIT AVE | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029062853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4017933100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 02/01/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA00641 | RI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PY01057 | 05 | RI | MEDICAID |