Basic Information
| Provider Information | |||||||||
| NPI: | 1821061680 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POPOVA | ||||||||
| FirstName: | YELENA | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 OCEANGATE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908024317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624996191 | ||||||||
| FaxNumber: | 8778602703 | ||||||||
| Practice Location | |||||||||
| Address1: | 3234 MARYSVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958151411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9166461200 | ||||||||
| FaxNumber: | 8778602703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 06/18/2015 | ||||||||
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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 | 207Q00000X | PA18255 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 363A00000X | PA18255 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | EFF: 1/31/12 | 05 | CA | MEDICAID | MACK RD-EFF 9/27/13 | 05 | CA | MEDICAID | P01453321-DV5277 | 01 | CA | RAILROAD MEDICARE | OTHER | EFF: 2/20/13 | 05 | CA | MEDICAID | EFF: 2/20/2013 | 05 | CA | MEDICAID | P01284219/DS9933 | 01 | CA | RAILROAD MEDICARE | OTHER | PA18255 | 05 | CA | MEDICAID |