Provider Demographics
NPI:1093727828
Name:YASSKIN, SANDRA (LOT)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:
Last Name:YASSKIN
Suffix:
Gender:F
Credentials:LOT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2901 JENNIFER DR
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-5755
Mailing Address - Country:US
Mailing Address - Phone:979-696-6661
Mailing Address - Fax:
Practice Address - Street 1:302 E 24TH ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77803-5303
Practice Address - Country:US
Practice Address - Phone:979-821-9474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100920174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX83012TMedicaid