Provider Demographics
NPI:1780119248
Name:YENKO, WILFRED (PHYSICAL EDUCATION)
Entity type:Individual
Prefix:
First Name:WILFRED
Middle Name:
Last Name:YENKO
Suffix:
Gender:M
Credentials:PHYSICAL EDUCATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9511 HOLMES LN
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4817
Mailing Address - Country:US
Mailing Address - Phone:347-342-2013
Mailing Address - Fax:
Practice Address - Street 1:213 OSBORN STREET
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212
Practice Address - Country:US
Practice Address - Phone:347-342-2013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY565058111390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program