Provider Demographics
NPI:1033108683
Name:YAMAMOTO, CHERYL (PA-C)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
Last Name:YAMAMOTO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3156 W MONTE CRISTO AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-3936
Mailing Address - Country:US
Mailing Address - Phone:310-200-7654
Mailing Address - Fax:
Practice Address - Street 1:20165 N 67TH AVE STE 107
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7004
Practice Address - Country:US
Practice Address - Phone:623-561-1590
Practice Address - Fax:623-561-0534
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3565363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ81571828Medicaid
AZ81571828Medicaid